§ 5100.15. Contents of treatment plan.

 (a)  A comprehensive individualized plan of treatment shall:

   (1)  Be formulated to the extent feasible, with the consultation of the patient. When appropriate to the patient’s age, or with the patient’s consent, his family, personal guardian, or appropriate other persons should be consulted about the plan.

   (2)  Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavorial, familial, educational, vocational, and developmental aspects of the patient’s situation.

   (3)  Set forth treatment objectives and prescribe an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives.

   (4)  Result from the collaborative recommendation of the patient’s interdisciplinary treatment team.

   (5)  Be maintained and updated with progress notes, and be retained in the patient’s medical record on a form developed by the facility and approved by the Deputy Secretary of Mental Health, as part of the licensing approval process.

 (b)  The treatment plan shall indicate what less restrictive alternatives were considered and why they were not utilized. If the plan provides for restraints, the basis for the necessity for such restraints must be stated in the plan under Chapter 13 (relating to use of restraints in treating patients/residents).

 (c)  Individual treatment plans shall be written in terms easily explainable to the lay person and a copy of the current treatment plan shall be available for review by the person in treatment.

 (d)  When the most appropriate form of treatment for the individual is not available or is too expensive to be feasible, that fact shall be noted on the treatment plan form.

Cross References

   This section cited in 55 Pa. Code §  5100.4 (relating to scope); and 55 Pa. Code §  5100.75 (relating to physical examination and formulation of individualized treatment plan).

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