3411 PLAN OF CARE DEVELOPMENT

3411.1 Each CSA shall coordinate the Plan of Care development for its enrolled consumers from the start of intake through discharge from the system of care, except that the Plan of Care development for consumers receiving:

1. (a) CBI, shall be coordinated by the consumer's CBI provider;
2. (b) ACT, shall be coordinated by the consumer's ACT provider; and
3. (c) Clubhouse services, shall be coordinated by the member's Clubhouse provider, if the member is not linked with a CSA, or a CBI or ACT provider. The Plan of Care development and implementation for such members shall be conducted in accordance with the requirements set forth in 22-A DCMR Chapter 39.

3411.2 The Plan of Care development process for consumers shall, at a minimum, include:

1. (a) The completion of a Diagnostic Assessment as described in § 3418;
2. (b) Development of a Plan of Care as described in § 3411;
3. (c) Consideration of the consumer's beliefs, values, and cultural norms in how, what, and by whom MHRS are to be provided;
4. (d) Consideration, screening, and assessment of the consumer for treatment using an appropriate evidence-based practice ("EBP") offered through a certified MHRS provider; and
5. (e) When coordinated by the CSA, assessment of the consumer for interest in and potential eligibility for Mental Health Supported Employment services, in accordance with the requirements set forth in 22-A DCMR Chapter 37.

3411.3 Court-appointed guardians for adults, children, and youth, and the parents/guardians or family members of children and youth shall be involved in the Plan of Care development process. The families and significant others of adult consumers may participate in the Plan of Care development process to the extent that the adult consumer consents to the involvement of family and significant others.

3411.4 The provider shall approve a Plan of Care within thirty (30) calendar days from when the provider obtains consent to treatment from the enrolled consumer. Approval of a Plan of Care shall be demonstrated by the dated and authenticated signature of an independently licensed qualified practitioner.

3411.5 Each CSA, or when applicable pursuant to § 3411.1, each CBI or ACT provider, shall develop and maintain a complete and current Plan of Care for each enrolled consumer after completing intake and assessment. The Plan of Care shall at a minimum describe all of the MHRS the provider will deliver to the consumer, as well as any services to be provided by another CSA, sub-provider, or specialty provider. The CSA or, if applicable, the CBI or ACT provider, is responsible for coordinating the development of the Plan of Care with any CSA, sub-provider, or specialty provider involved in the provision of services.

3411.6 The Plan of Care shall be person-centered and include the following elements:

(a) Overall broad, long-term goal statement(s) that captures the consumer's and/or family's short- and long-term goals for the future, ideally written in first-person language. This shall include the consumer's self-identified recovery goals;

(b) List or statement of individual or family strengths that support goal(s) accomplishment. These include abilities, talents, accomplishments, and resources;

(c) List or statement of barriers that pose obstacles to the consumer's and/or family's ability to accomplish the stated goal(s). These include symptoms, functional impairments, lack of resources, consequences of behavioral health issues, and other challenges;

(d) Statement of objectives that identify the short-term consumer and/or family changes in behavior, function, or status that can help overcome the identified barriers and are building blocks toward the eventual accomplishment of the long-term goal(s). Objective statements describe outcomes that are measurable and include individualized target dates to be accomplished within the scope of the plan;

(e) Intervention statements that describe the treatment and recovery services to be utilized to reduce or eliminate the barriers identified in the plan and support objective and eventual goal(s) accomplishment. Interventions are specific to each objective and the consumer's and/or family's stage of change. Intervention statements identify who will deliver the

service, what will be delivered, when it will be delivered, and the purpose of the intervention. Natural support interventions should also be included in the plan and include those non-billable supports delivered by resources outside of the formal behavioral health service-delivery system. When appropriate and applicable, EBP shall be incorporated into the intervention statement; and

(f) Provide for the delivery of services in the least restrictive environment that is appropriate for the consumer.

SOURCE: Final Rulemaking published at 48 DCR 10297 (November 9, 2001); as amended by Final Rulemaking published at 51 DCR 9308 (October 1, 2004); as amended by Final Rulemaking published at 52 DCR 5682 (June 17, 2005); as amended by Final Rulemaking published at 57 DCR 10392, 10393 (November 5, 2010); as amended by Notice of Emergency and Proposed Rulemaking published at 58 DCR 1482 (February 18, 2011)[EXPIRED]; as amended by Notice of Final Rulemaking published at 58 DCR 3476, 3478 (April 22, 2011); as amended by Notice of Final Rulemaking published at 58 DCR 8366, 8369 (September 30, 2011); as amended by Final Rulemaking published at 67 DCR 10674 (September 4, 2020).