Rule 5122-27-03 | Treatment planning.
(A) Each provider required by Chapter 5122-27 of the Administrative Code to maintain an individual client record (ICR) for a certified service, shall also develop an individualized treatment plan (ITP) for each client.
(B) The development of the ITP is a collaborative process between the client and service provider based on a diagnostic assessment, a continuing assessment of needs, and the identification of interventions and services appropriate to the individuals diagnosis and other related needs. An addiction treatment case management plan of care is based upon the diagnostic assessment or upon a separate case management assessment. Providers may accept a case management assessment from another provider as long as the assessment was completed with the preceding twelve months. Prior assessments shall be reviewed and updated prior to developing the case management plan.
(C) The ITP and addiction treatment case management plan of care shall document, at minimum, the following:
(1) A description of the specific mental health or addiction services and supports needs of the client;
(2) Anticipated treatment goals and objectives based upon the needs identified in this rule. Such goals shall be mutually agreed upon by the provider and the client. If these goals are not mutually agreed upon, the reason needs to be fully documented in the ICR;
(3) Name or description of all services being provided, with the exception of crisis intervention service provided in accordance with rule 5122-29-10 of the Administrative Code;
(4) Frequency of treatment services, and anticipated duration (e.g. sixty days, six months, a future date) of treatment services. A provider is not required to update a treatment plan solely because the anticipated period of treatment has passed;
(5) Documentation that the plan has been reviewed with the active participation of the client, and, as appropriate, with involvement of family members, parents, legal guardians or custodians or significant others;
(6) As relevant, the inability or refusal of the client to participate in service and treatment planning and the reason given;
(7) The dated signature of the agency staff member responsible for developing the ITP or addiction treatment case management plan of care, and documented evidence of clinical supervision of staff developing the plan, as applicable. Evidence of clinical supervision may be by supervisor signature on the ITP, addiction treatment case management plan of care, or other documentation by the supervisor in the ICR; and,
(8) For clients receiving addiction services treatment, the level of care to which client is admitted.
(D) A provider may develop separate ITP and addiction treatment case management plans or integrate the ITP and addiction treatment case management plan of care into one plan ("integrated plan").
(E) An initial ITP may be developed. An initial ITP is one which documents the immediate clinical needs of the client, and includes the items required of an ITP in paragraphs (C)(1),(C)(3), and (C)(7) of this rule to meet those immediate needs.
(F) Schedule of completion of ITP and addiction treatment case management plan of care:
(1) An initial ITP developed in accordance with paragraph (E) of this rule, if the provider chooses to develop an initial plan, shall be developed within seven days of completion of the assessment or at the time of the first face-to-face contact following assessment, whichever is later. A provider is not required to develop an initial ITP.
(2) An addiction treatment case management plan of care for a person receiving SUD case management services in accordance with rule 5122-29-09 of the Administrative Code shall be developed within seven days of completion of the assessment or at the time of the first face-to-face contact following assessment, whichever is later.
(3) A comprehensive ITP must be completed within five sessions or one month of admission, whichever is longer, excluding crisis intervention service provided in accordance with rule 5122-29-10 of the Administrative Code. This requirement is applicable regardless of whether the provider first developed an initial ITP in accordance with paragraph (E) of this rule.
(G) The addiction treatment case management plan of care shall be based upon a documented reassessment of case management needs. The reassessment must occur at least every ninety days.
(H) Schedule of review.
(1) An integrated ITP shall be reviewed at least every ninety days, and sooner if clinically indicated.
(2) An addiction treatment case management plan of care shall be reviewed at least every ninety days, and sooner if clinically indicated.
(3) An ITP that does not contain an addiction treatment case management plan of care shall be reviewed:
(a) When a service is added or terminated.
(b) When clinically indicated.
(c) When there is a change in the addiction treatment level of care, excluding a change in sub-levels, e.g. a change from level 3.5 to level 3.1 does not require a review of the treatment plan.
(d) When requested by the client.
(e) At least every twelve months.
(I) Documentation of ITP and addiction treatment case management plan of care reviews shall contain:
(1) Results of the review:
(a) Updates to the ITP and addiction treatment case management plan of care as applicable, e.g. new goals, discontinued or completed goals, adjusted anticipated duration, etc.; or
(b) Documentation that a review occurred without changes to the ITP and addiction treatment case management plan of care.
(2) Evidence that the plan has been reviewed with the active participation of the client, and, as appropriate, with involvement of family members, parents, legal guardians or custodians or significant others;
(3) As relevant, the inability or refusal of the client to participate and the reason given; and
(4) The signature of the provider staff member responsible for completing the review, the date on which it was completed; and documented evidence of clinical supervision of staff completing the review, as applicable.
Supplemental Information