A. An administrator
shall ensure that a treatment plan is developed and implemented for each
resident that:
1. Is based on the medical
history and physical examination or nursing assessment required in
R9-10-707(A)(6) or
(E)(1)(a) and the behavioral health
assessment required in
R9-10-707(A)(9) or
(10) and on-going changes to the behavioral
health assessment of the resident;
2. Is completed:
a. By a behavioral health professional or a
behavioral health technician under the clinical oversight of a behavioral
health professional, and
b. Before
the resident receives physical health services or behavioral health services or
within 48 hours after the assessment is completed;
3. Is documented in the resident's medical
record within 48 hours after the resident first receives physical health
services or behavioral health services;
4. Includes:
a. The resident's presenting issue;
b. The physical health services or behavioral
health services to be provided to the resident;
c. The signature of the resident or the
resident's representative and date signed, or documentation of the refusal to
sign;
d. The date when the
resident's treatment plan will be reviewed;
e. If a discharge date has been determined,
the treatment needed after discharge; and
f. The signature of the personnel member who
developed the treatment plan and the date signed;
5. If the treatment plan was completed by a
behavioral health technician, is reviewed and signed by a behavioral health
professional within 24 hours after the completion of the treatment plan to
ensure that the treatment plan is complete and accurate and meets the
resident's treatment needs; and
6.
Is reviewed and updated on an on-going basis:
a. According to the review date specified in
the treatment plan,
b. When a
treatment goal is accomplished or changed,
c. When additional information that affects
the resident's behavioral health assessment is identified, and
d. When a resident has a significant change
in condition or experiences an event that affects treatment.
B. An administrator
shall ensure that:
1. A request for
participation in developing a resident's treatment plan is made to the resident
or the resident's representative,
2. An opportunity for participation in
developing the resident's treatment plan is provided to the resident or the
resident's representative, and
3.
The request in subsection (B)(1) and the opportunity in subsection (B)(2) are
documented in the resident's medical record.