3828.1 Each MHCRF shall participate in the development and review of an Individual Treatment Plan (ITP) with the CMHS designated case manager and shall maintain a copy of the ITP in the resident's record. The MHCRF shall describe in writing, the following:

1. (a) The resident's functional strengths and limitations in performing daily living activities;
2. (b) Any medical or health issues which are relevant to the services needed by the resident;
3. (c) Clinical needs of the resident;
4. (d) Goals, objectives and specific interventions designed to attain goals; and
5. (e) Client's legal status.

3828.2 Each MHCRF shall write the name, address, and telephone number of the provider of each service the resident receives for inclusion in the ITP.

3828.3 The Residence Director and residential staff shall assist in reviewing and updating the ITP in collaboration with the CMHS designated case manager, the resident and his or her guardian, if any, and a multi-disciplinary team which may include, but not be limited to, the resident's attending physician, psychiatrist, social worker, and significant others.

3828.4 The initial ITP shall be developed by the CMHS designated case manager prior to the time the resident moves into the MHCRF and shall be revised, if needed, within thirty (30) days. The ITP shall be reviewed and updated as often as necessary but not less than every three (3) months. The MHCRF may request a review of the ITP by the resident's treatment team through the CMHS designated case manager.

3828.5 The resident shall have the right to participate in planning all phases of his or her ITP, may request participation of a family member, and shall be offered the opportunity to sign his or her ITP or indicate disagreement with particular aspects of the plan or the whole of the plan.

SOURCE: Final Rulemaking published at 42 DCR 569, 596 (January 27, 1995).