N.Y. Comp. Codes R. & Regs. tit. 14, § 511-2.8 – Treatment planning.

(a) Treatment planning shall be an ongoing and individualized process to ensure the services included within the treatment plan are medically necessary and to track the child’s progress towards stated goals and objectives. The treatment plan shall be developed and updated in collaboration with the child and family in accordance with and individualized to the unique needs, goals and preferences of the child and the child’s family.
(b) The treatment plan for a child shall be developed by the CMHRS program. For any rehabilitative service(s) provided pursuant to formal agreement with a designated provider, the development and ongoing review of the treatment plan shall include regular collaboration and coordination in accordance with protocols and procedures outlined in such agreement.
(c) The treatment plan shall include identification and documentation of the following:
1. (1) the child's mental health diagnosis or symptoms of a mental illness exhibited by the child; or a notation that the diagnosis may be found in a specific assessment document in the child’s case record;
2. (2) the child's needs and strengths;
3. (3) the child's treatment goals and objectives and the specific services, service components or activities necessary to accomplish those goals and objectives, as well as their projected frequency and duration;
4. (4) the name and title of the staff providing the specific services; and
5. (5) criteria for determining when the child should be discharged from the services.
(d) Treatment plans shall be completed no later than 30 days after admission. The treatment plan for a child receiving services reimbursed by Medicaid through a managed care plan or on a fee-for-service basis shall be signed by licensed practitioner and shall include a projected schedule for service delivery and the projected frequency and duration of each type of planned therapeutic session or encounter.
(e) The child and family’s participation in treatment planning shall be documented by the signature of the child or the signature of the person who has legal authority to consent to health care on behalf of the child.
1. (1) Reasons for non-participation by the individual are documented in the treatment plan.
2. (2) The child's family and/or collaterals may participate as appropriate in the development of the treatment plan. Collaterals participating in the development of the treatment plan shall be specifically identified in the plan.
(f) Treatment plans shall be reviewed and updated as necessary based upon the child’s progress, changes in circumstances, the effectiveness of services, or other appropriate considerations. The periodic review of the treatment plan shall include the following:
1. (1) assessment of the progress of the child regarding the mutually agreed upon goals in the treatment plan;
2. (2) adjustment of goals and treatment objectives, time periods for achievement, intervention strategies or initiation of discharge planning, as appropriate;
3. (3) recommendation/inclusion of additional or other services such as other rehabilitative or support services within CMHRS, where appropriate; and
4. (4) the signature of licensed practitioner within his/her scope of practice, as defined by NYS State Education Law, involved in or recommending the treatment.
(g) For services provided to a child enrolled in a managed care plan which is certified by the Commissioner of the Department of Health or commercial insurance plan which is certified or approved by the Superintendent of the Insurance Department, treatment plans may be reviewed pursuant to such other plan requirement as shall apply.
(h) Progress notes shall be recorded and signed by the staff member(s) who provided services to the child upon each occasion of service. Progress notes shall include, at a minimum:
1. (1) the date and duration of each service provided;
2. (2) a summary of the service(s) provided and modality;
3. (3) a description of the progress made toward the child’s goals;
4. (4) identification of any necessary changes to the elements of the child’s treatment plan;
5. (5) the location where the service was provided, whether collaterals were seen;
6. (6) the name and title of the staff member providing each service; and
7. (7) a progress note must also be completed for any significant event and/or unexpected incident.