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 guardian� and
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.