(a) Treatment planning is an ongoing process of assessing the mental health status and needs of the individual, establishing his or her treatment and rehabilitative goals, and determining what services may be provided by the clinic to assist the individual in accomplishing these goals. The treatment planning process includes, where appropriate, a means for determining when the individual’s goals have been met to the extent possible in the context of the program, and planning for the appropriate discharge of the individual from the clinic. The treatment planning process is a means of reviewing and adjusting the services necessary to assist the individual in reaching the point where he or she can pursue life goals such as employment or education, without impediment resulting from his or her illness.

(b) For recipients who are Medicaid fee-for-service beneficiaries, the initial treatment plan shall be completed not later than 30 days after admission. For any other payer or plan, initial treatment plans shall be completed pursuant to such other payer or plan’s requirement as shall apply.

(c) The treatment plan shall include identification and documentation of the following:

(d) Treatment plans shall be reviewed no less frequently than annually based on the date of admission or additionally as determined by the recipient’s treating clinician. Treatment plan reviews shall include the input of relevant staff, as well as the recipient, family members and collaterals, as appropriate. The treatment plan review may be documented in progress notes and shall include the following:

(e) Treatment plans shall be updated when new services are added, service intensity is increased or as necessary as determined by the recipient’s treating clinician. When the treatment plan is updated the treating clinician as appropriate, pursuant to paragraph (c)(7) of this section, shall sign the updated treatment plan. All other changes to information in the treatment plan shall only require the treating clinician’s signature and may be recorded in progress notes.

(f) Recipient participation in the treatment planning process, including initial treatment planning and treatment plan reviews, shall be documented by notation in the record of the participation of the recipient or of the person who has legal authority to consent to health care on behalf of the recipient, or, in the case of a child, of a parent, guardian, or other person who has legal authority to consent to health care on behalf of the child, as well as the child, where appropriate. The recipient's family and/or collaterals may participate as appropriate in the development of the treatment plan. Collaterals participating in the development of the treatment plan shall be specifically identified in the plan.

(g) Progress notes shall be recorded by the clinical staff member(s) who provided services to the recipient upon each occasion of service. These notes must summarize the service(s) provided, update the recipient’s progress toward his or her goals, and include any recommended changes to the elements of the recipient’s treatment plan. The progress notes shall also document the date and duration of each service provided, the location where the service was provided, whether collaterals were seen, and the name and title of the staff member providing each service. The need for complex care management and the actions taken by the clinic in response to this need shall also be recorded in the progress notes.