Policy Manual


Individualized Plan of Care      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: 

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Executive Director  10/08  10-1-2008
Related Document Code Related Document Name Type

Procedure:  .

An individualized plan of care (Treatment Plan) will be developed for each client based on an initial assessment.Initial plans of care will be developed as required by regulatory standards relevant to each service.

The Plan of Care will include:

1)      A specific problem statement or statements as defined by the client and/or guardianand clinician.

2)      A list of agreed upon long-term and short-term goals based upon client needs, desired outcomes, and a projection of when such goals will be attained.

3)      Objectives stated in terms that allow objective measurement of progress.

4)      Modalities and frequency of treatment, rehabilitation and support to be provided.

5)      Multi-disciplinary input and specification of treatment responsibilities.

6)      Client, parent, and/or guardian input and signature.

7)      Signatures of all people participating in the development of the plan.

8)      Name of Community Care provider(s) and all service providers including those external to the Agency.

9)  A description of any physical handicap and any accommodations necessary to provide the same or equal services and benefits as those afforded non-disabled individuals.

10)  Criteria for discharge and discharge plan.

11)  Documentation of unmet service and support needs.

12)  A copy of the plan shall be provided to the client, parent, and/or guardian within one week of completion and reviewed with the client to afford the client the opportunity to disagree with any aspects of the plan.

13)  Individual service plans will be revised at any time there are changes in services or providers and at a minimum every 90 days.Reviews will assess service plan implementation, progress toward achieving goals, and the continuing appropriateness of service plan goals.