1. (1) Each patient must have a written person-centered treatment/recovery plan developed by clinical staff and patient no later than seven calendar days after admission. Standards for developing a treatment/recovery plan include, but are not limited to:

   1. (i) If the patient is a minor, the treatment/recovery plan must also be developed in consultation with the patient’s parent or guardian unless the minor is being treated without parental consent as authorized by Mental Hygiene Law section 22.11.

   2. (ii) For patients moving directly from one program to another, the existing treatment/recovery plan may be used if there is documentation that it has been reviewed and, if necessary, updated within 24 hours of transfer.

      (b) Treatment/recovery plan.

      The treatment/recovery plan must:

2. (1) include each diagnosis for which the patient is being treated;
3. (2) address patient identified problem areas specified in the admission assessment and concerns which may have been identified subsequent to admission, and identify methods and treatment approaches that will be utilized to achieve the goals developed by the patient and primary counselor;
4. (3) identify a single member of the clinical staff responsible for coordinating and managing the patient's treatment who shall approve and sign (physical or electronic signature) such plan; and
5. (4) be reviewed, signed and dated by the physician within 10 days of admission;

6. (5) where a service is to be provided by any other program off site, the treatment/recovery plan must contain a description of the nature of the service, a record that referral for such service has been made, and the results of the referral.

   (c) Continuing review of the treatment/recovery plan.

7. (1) The clinical staff shall ensure that the treatment/recovery plan is included in the patient record and that all treatment is provided in accordance with the individual treatment/recovery plan.

8. (2) If, during the course of treatment, revisions to the treatment/recovery plan are determined to be clinically necessary, the plan shall be revised accordingly by the clinical staff member.

   (d) Progress notes.

   A progress note shall be written, signed and dated by the clinical staff member or another clinical staff member familiar with the patient's care no less often than once per week. Such progress note shall provide a chronology of the patient's participation in all significant services provided, their progress related to the initial services or the goals established in the treatment/recovery plan and be sufficient to delineate the course and results of treatment/services.

   (e) Discharge and planning for level of care transitions.

9. (1) The discharge planning process shall begin as soon as the patient is admitted and shall be considered a part of the treatment planning process. The plan for discharge and level of care transitions shall be developed in collaboration with the patient and any significant other(s) the patient chooses to involve. If the patient is a minor, the discharge plan must also be developed in consultation with the patient’s parent or guardian, unless the minor is being treated without parental consent as authorized by Mental Hygiene Law section 22.11.

10. (2) Discharge should occur when:

    1. (i) the patient meets criteria documented by the OASAS level of care determination protocol for an alternate level of care and has attained skills in identifying and managing cravings and urges to use substances, stabilized psychiatric and medical conditions, and has identified a plan for returning to their community;
    2. (ii) the patient has received maximum benefit from the service provided by the program; or
    3. (iii) the individual is disruptive and/or fails to comply with the program’s written behavioral standards, provided that the individual is offered a referral and connection to another treatment program.
11. (3) No patient shall be discharged without a discharge plan which has been completed and reviewed by the multi-disciplinary team prior to the discharge of the patient. This review may be part of a regular treatment/recovery plan review. The portion of the discharge plan which includes the referrals for continuing care shall be given to the patient upon discharge. This requirement shall not apply to patients who leave the program without permission, refuse continuing care planning, or otherwise fail to cooperate.

12. (4) The discharge plan shall be developed by the clinical staff member, who, in the development of such plan, shall consider the patient's self-reported confidence in maintaining their health and recovery and following an individualized re-occurrence prevention plan. The clinical staff member shall also consider an assessment of the patient's home and family environment, vocational/educational/employment status, and the patient's relationships with significant others. The purpose of the discharge plan shall be to establish the level of clinical and social resources available to the individual post-treatment and the need for the services for significant others. The plan shall include, but not be limited to, the following:

    1. (i) identification of any other treatment, rehabilitation, self-help and vocational, educational and employment services the patient will need after discharge;
    2. (ii) identification of the type of residence, if any, that the patient will need after discharge;
    3. (iii) identification of specific providers of these needed services;
    4. (iv) specific referrals and initial appointments for these needed services; and
    5. (v) the patient, and their family/significant other(s) shall be offered naloxone education and training and a naloxone kit or prescription.
13. (5) A discharge summary which includes the course and results of care and treatment must be prepared and included in each patient's case record within 20 days of discharge.

(a) Treatment / recovery plan.