N.Y. Comp. Codes R. & Regs. tit. 14, § 595.11 – Service planning.

(a) Services provided within a residential program, including a CREDIT program, shall be provided in accordance with a service plan developed within four weeks of admission to the program. In the case of a residence that is a CREDIT program, the initial service plan must be developed within three days of admission. At the time of admission, an admission note shall be prepared by a qualified mental health staff person which, at a minimum, indicates a description of the needs of the individual, as well as a brief description of the services necessary to meet these needs during the initial period after admission.
(b) Such plan shall be developed by the staff of the program, the resident and any collateral identified for participation in planning, as appropriate and desired by the resident. The service plan shall be reviewed and signed by a qualified mental health staff person. The individualized written service plan shall be a mutually agreed upon plan which, at a minimum, identifies the following:
1. (1) statement of resident's readiness to participate in the services provided by the program; or
2. (2) statement of activities which will be provided to engage resident to participate in the services provided by the program; and
3. (3) statement of the resident's needs and strengths;
4. (4) statement of service goals and objectives;
5. (5) identification of the services to be provided;
6. (6) proposed time periods; and
7. (7) efforts to coordinate services with other providers.
(c) Progress notes shall be recorded by authorized program staff members. Such notes shall be prepared at least monthly for all programs other than the CREDIT program, and shall indicate the type of services which have been provided, any significant events which have occurred and, if appropriate, any recommendations for changes to the goals and objectives of the service plan. For the CREDIT program, progress notes should be completed weekly.
(d) The individualized written service plan shall be reviewed at least once every three months, with the initial review occurring three months from the date of admission. The review shall include participation of staff involved in the provision of services to the resident, the resident, and/or if appropriate and with the approval of the resident, the resident's family or other collateral. Such review shall include the following:
1. (1) assessment of the progress of the resident in regard to mutually agreed upon goals and objectives in the individualized written service plan;
2. (2) recommendations for adjustment of goals and objectives, time periods for achievement, intervention strategies or the initiation of discharge planning; and
3. (3) review of the individualized written service plan and signed approval by a qualified mental health staff person.
(e) As a part of the service planning process for each resident, the provider shall ensure that:
1. (1) a resident shall have access to a copy of his/her individualized written service plan at all times;
2. (2) a resident shall be encouraged to determine the participants to be involved in the planning process;
3. (3) entries made in the service plan shall be in the resident's own words or reflect a reasonable substitute for a resident's limitation for verbal expression;
4. (4) a service plan shall record planned interventions, document the success or failure of such interventions and include a plan for ongoing supports after discharge from the program; and
5. (5) a service plan shall reflect the participation of treatment and rehabilitation personnel with specialized expertise relevant to the need of the resident.
(f) In addition, programs receiving reimbursement under the Medicaid Assistance Program, shall comply with all other service authorization and service planning requirements set forth in section 593.6 of this Title.