TREATMENT STANDARDS
§ 5200.31. Treatment planning.
(a) For each individual receiving services, a mental health professional or mental health worker under the supervision of a mental health professional shall complete an assessment of the behavioral health, medical, psychological, social, vocational, educational and other factors important to the individual prior to the development of the initial comprehensive treatment plan.
(b) An initial comprehensive treatment plan shall be developed, reviewed and approved within 30 days of the intake and assessment with every individual who continues to participate in the treatment process in accordance with the following:
(1) The mental health professional or the mental health worker under the supervision of the mental health professional and the individual receiving services shall develop, sign and date the initial treatment plan.
(2) If the individual is receiving psychotherapy and other clinical services, the psychiatrist or advanced practice professional shall review, approve, sign and date the initial treatment plan.
(3) If the individual is receiving medication management services only, the psychiatrist, physician, certified registered nurse practitioner or physician assistant responsible for prescribing and monitoring the use of the medication shall review, approve, sign and date the initial treatment plan.
(4) For individuals under an involuntary outpatient commitment, the mental health professional or advanced practice professional providing services and the individual shall develop, review, sign and date the initial treatment plan. The treatment plan shall be reviewed and signed by the psychiatrist as part of the oversight of the treatment services provided.
(c) The treatment plan must be based upon the assessment and shall:
(1) Specify the goals and objectives of the plan, prescribe an integrated program of therapeutic activities and experiences, specify the modalities to be utilized and the expected duration of services and the person or persons responsible for carrying out the plan.
(2) Be directed at specific outcomes and connect these outcomes with the treatment modalities and activities proposed.
(3) Be developed with the active involvement of the individual receiving services and shall include strengths and needs. The treatment plan may also address individual preferences, resilience and functioning.
(4) For children and adolescents under 14 years of age, be developed and implemented with the consent of parents or guardians and include their participation in treatment as required by statute or regulation.
(5) Specify an individualized treatment program for each individual, which shall include clinically appropriate services such as psychiatric evaluation and diagnosis, psychological evaluation, individual, group and family psychotherapy, behavior therapy, crisis intervention services, medication evaluation and management, and similar services.
(d) The treatment plan shall be reviewed and updated throughout the duration of treatment as follows:
(1) For individuals under an involuntary outpatient commitment, the treatment plan shall be reviewed and updated every 30 days by the mental health professional or advanced practice professional providing treatment services and the individual receiving services. The treatment plan update shall be reviewed and signed by the psychiatrist as part of the oversight of treatment services provided.
(2) For individuals voluntarily receiving treatment, the treatment plan shall be reviewed and updated at a minimum of every 180 days by the mental health professional, mental health worker under the supervision of a mental health professional, certified registered nurse practitioner or physician assistant providing treatment services and the individual receiving services.
(3) The treatment plan update shall be signed and dated by the mental health professional, mental health worker under the supervision of a mental health professional, certified registered nurse practitioner or physician assistant providing treatment services.
(4) The mental health professional or mental health worker shall request the individual to sign and date the treatment plan update. In the event the individual does not sign the treatment plan update, the mental health professional or mental health worker shall document the request in the record.
(e) All treatment services shall be provided in accordance with the identified goals in the treatment plan and updates.
(f) The treatment plan and updates shall be kept in the individual record.
(g) The treatment plan shall be reviewed on an annual basis by the psychiatrist or advanced practice professional throughout the course of treatment from the psychiatric outpatient clinic and documented in the individual record.
Authority The provisions of this § 5200.31 amended under section 1021 of the Human Services Code (62 P.S. § 1021); sections 105 and 112 of the Mental Health Procedures Act (50 P.S. § § 7105 and 7112); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
Source The provisions of this § 5200.31 amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (247794) and (368119).
Cross References This section cited in 55 Pa. Code § 5200.52 (relating to treatment planning).
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