Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 6. (a) The plan of care is an individualized treatment plan that integrates all components and aspects of care, including services, interventions, and supports that are deemed medically necessary or clinically indicated.

(b) The plan of care must include all indicated medical and behavioral support services needed by a member in order to assist the member in the following:

1. (1) Remaining in the home or community.
2. (2) Functioning at the highest level of independence possible.
3. (3) Achieving treatment goals.

(c) The CMHW services plan of care developed within the team, with member and family input and inclusion, must meet the following criteria:

1. (1) Be developed for each member based upon the member's unique strengths and needs, as ascertained in the evaluation or assessment.
2. (2) Reflect the member's and the family's preferences and choices for services and providers.

3. (3) Contain goals that delineate the following:

   1. (A) Clear objectives.
   2. (B) Resources, including the child and family team member or members that will assist the member in meeting each goal.
   3. (C) Service duration and frequency, based upon the member's level of need and functional impairments.

(d) In addition to the plan of care, the team shall develop a crisis plan that includes the following components:

1. (1) Anticipated crisis or crises that the member may experience based upon historical information.
2. (2) Potential triggers that may lead to a crisis situation involving the member.
3. (3) Interventions that have either worked or not worked in deescalating a crisis situation in the past.
4. (4) The plan of action for the member, the member's family, and members of the child and family team in the event of a crisis.
5. (5) Identified resources available to assist the member and the member's family in the event of a crisis.

(e) The plan of care and the crisis plan must be submitted to the office for review and approval prior to the delivery of CMHW services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-6; filed Dec 18, 2013, 11:13 a.m.: 20140115-IR-405130211FRA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; readopted filed Jul 28, 2022, 2:21 p.m.: 20220824-IR-405220205RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)