Minnesota Administrative Rules

9530.6425 INDIVIDUAL TREATMENT PLANS.

Subpart 1.

General.

Individual treatment plans for clients in treatment must be completed within seven calendar days of completion of the assessment summary. Treatment plans must continually be updated, based on new information gathered about the client's condition and on whether planned treatment interventions have had the intended effect. Treatment planning must include ongoing assessment in each of the six dimensions according to part 9530.6422, subpart 2. The plan must provide for the involvement of the client's family and those people selected by the client as being important to the success of the treatment experience at the earliest opportunity, consistent with the client's treatment needs and written consent. The plan must be developed after completion of the comprehensive assessment and is subject to amendment until services to the client are terminated. The client must have an opportunity to have active, direct involvement in selecting the anticipated outcomes of the treatment process and in developing the individual treatment plan. The individual treatment plan must be signed by the client and the alcohol and drug counselor. The individual treatment plan may be a continuation of the initial services plan required in part 9530.6420.

Subp. 2.

Plan contents.

An individual treatment plan must be recorded in the six dimensions listed in part 9530.6422, subpart 2, item B, and address each problem identified in the assessment summary, and include:

A.

specific methods to be used to address identified problems, including amount, frequency, and anticipated duration of treatment service. The methods must be appropriate to the client's language, reading skills, cultural background, and strengths;

B.

resources to which the client is being referred for problems when problems are to be addressed concurrently by another provider; and

C.

goals the client must reach to complete treatment and have services terminated.

Subp. 3.

Progress notes and plan review.

A.

Progress notes must be entered in a client's file weekly or after each treatment service, whichever is less frequent, by the staff person providing the service. The note must reference the treatment plan. Progress notes must be recorded and address each of the six dimensions listed in part 9530.6422, subpart 2, item B. Progress notes must:

(1)

be entered immediately following any significant event. Significant events include those events which have an impact on the client's relationship with other clients, staff, the client's family, or the client's treatment plan;

(2)

indicate the type and amount of each treatment service the client has received;

(3)

include monitoring of any physical and mental health problems and the participation of others in the treatment plan;

(4)

document the participation of others; and

(5)

document that the client has been notified of each treatment plan change and that the client either does or does not agree with the change.

B.

Treatment plan review must:

(1)

occur weekly or after each treatment service, whichever is less frequent;

(2)

address each goal in the treatment plan that has been worked on since the last review;

(3)

address whether the strategies to address the goals are effective, and if not, must include changes to the treatment plan; and

(4)

include a review and evaluation of the individual abuse prevention plan according to Minnesota Statutes, section 245A.65.

C.

All entries in a client's record must be legible, signed, and dated. Late entries must be clearly labeled "late entry." Corrections to an entry must be made in a way in which the original entry can still be read.

Subp. 3a.

Documentation.

Progress notes and plan review do not require separate documentation if the information in the client file meets the requirements of subpart 3, items A and B.

Subp. 4.

Summary at termination of services.

An alcohol and drug counselor must write a discharge summary for each client. The summary must be completed within five days of the client's service termination or within five days from the client's or program's decision to terminate services, whichever is earlier.

A.

The summary at termination of services must be recorded in the six dimensions listed in part 9530.6422, subpart 2, item B, and include the following information:

(1)

client's problems, strengths, and needs while participating in treatment, including services provided;

(2)

client's progress toward achieving each of the goals identified in the individual treatment plan;

(3)

reasons for and circumstances of service termination; and

(4)

risk description according to part 9530.6622.

B.

For clients who successfully complete treatment, the summary must also include:

(1)

living arrangements upon discharge;

(2)

continuing care recommendations, including referrals made with specific attention to continuity of care for mental health problems, as needed;

(3)

service termination diagnosis; and

(4)

client's prognosis.

Statutory Authority:

MS s 241.021; 245A.03; 245A.09; 254A.03; 254B.03; 254B.04

History:

29 SR 129; 32 SR 2268

Published Electronically:

October 15, 2013