1. (a) Each service delivery site shall develop an individualized treatment or habilitation plan for each client based upon:

   1. (1) an evaluation of his condition, assets and needs; and
   2. (2) information gathered during the admission assessment process.

2. (b) The treatment or habilitation plan shall be documented in the client record as follows and shall:

   1. (1) provide a systematic approach to the treatment or habilitation of the client;
   2. (2) substantiate the appropriateness of treatment or habilitation goals;
   3. (3) designate clinical responsibility for the development and implementation of the plan;
   4. (4) include at least the diagnosis to ensure consistency;
   5. (5) include time‑specific measurable goals; and
   6. (6) provide a summary of client, and if appropriate, family strengths and weaknesses.
3. (c) The plan shall be reviewed at least annually; and when medically or clinically indicated, the plan shall be revised accordingly.
4. (d) The client shall have the opportunity to participate in the development and implementation of the treatment and habilitation plan.

History Note: Authority G.S. 148‑19(d);
Eff. January 4, 1994;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.