37.106.1720    INDIVIDUALIZED TREATMENT PLANNING

(1) Based upon the findings of the assessment(s), the facility shall initiate an individualized treatment plan for each patient within 24 hours of admission. The treatment plan must conform to requirements outlined in 53-21-162, MCA, be completed within ten days of admission, and:

(a) identify treatment team members, from within and outside of the facility, who are involved in the patient's treatment or care;

(b) specifically state measurable treatment plan objectives that serve the patient in the least restrictive and most culturally appropriate therapeutic environment;

(c) describe the service or intervention with sufficient specificity to demonstrate the relationship between the service or intervention and the stated objective;

(d) identify the staff person and program responsible for each treatment service to be provided;

(e) include the patient's guardian or power of attorney's signature indicating participation in the development of the treatment plan. If the patient's or guardian's participation is not possible or inappropriate, written documentation must indicate the reason;

(f) include the signature and date of the facility's licensed mental health professional and of the person(s) with primary responsibility for implementation of the treatment plan indicating development and ongoing review of the plan; and

(g) state the criteria for discharge, including the patient's level of functioning which will indicate when a particular service is no longer required.

(2) The treatment plan must be reviewed at least every 30 days for each patient and whenever there is a significant change in the patient's condition. A change in level of care or referrals for additional services must be included in the treatment plan.

(3) The treatment plan review must be conducted by at least one licensed mental health professional from the facility and include persons with primary responsibility for implementation of the plan. Other staff members must be involved in the review process as clinically indicated.

(4) A treatment team meeting for establishing an individual treatment plan and for treatment plan review must be conducted face-to-face and include:

(a) the patient as clinically appropriate;

(b) the patient's guardian or the holder of the patient's power of attorney if applicable;

(c) case manager, if the patient has one; and

(d) peer support, or adult friend or family member may be invited to participate in the treatment planning or treatment plan review meeting, at the request of and upon written consent of the patient, and as deemed clinically appropriate by the patient's treatment team, prior to the scheduling of the meeting.

(5) The treatment plan review must be comprehensive with regard to the patient's response to treatment and result in either an amended treatment plan or a statement of the continued appropriateness of the existing plan. The results of the treatment plan review must be entered into the patient's clinical record. The documentation must include a description of the patient's functioning and justification for each patient goal.

(6) If the facility develops separate treatment plans for each service, the treatment plans must be integrated with one another and a copy of each treatment plan must be kept in the patient's record.

(7) Minimum components of treatment plans include:

(a) assessment, medication administration and management;

(b) discharge planning;

(c) assistance with activities of daily living;

(d) patient education;

(e) individual, group, and family therapies; and

(f) physical activity.

(8) Patient need and the patient's treating psychiatrist or mental health professional determine the length of stay.

(a) The maximum length of stay for a patient who is involuntarily committed is limited to the period authorized by the court order of commitment. Extension of commitment to a BHIF pursuant to 53-21-128, MCA, is not permitted.

History: 53-21-194, MCA; IMP, 53-21-128, 53-21-162, 53-21-194, MCA; NEW, 2009 MAR p. 1801, Eff. 10/16/09.