(a) Programs providing residential services for any or all elements of care must:

1. (1) as soon as possible after admission, develop a patient-centered, interdisciplinary treatment/recovery plan or service plan, which includes problem formulation and short-term, measurable treatment/recovery goals and activities designed to achieve those goals. This plan should be developed in collaboration with the resident; and

2. (2) review and revise, if necessary, the treatment/recovery plan or service plan in collaboration with the resident monthly (rehabilitation and reintegration) and weekly (stabilization) after admission and document accordingly.

   (b) Treatment/recovery plan.

3. (1) Each resident must have a written patient-centered treatment/recovery plan, or a service plan where appropriate, developed by the responsible clinical staff member and resident as soon as possible after admission. Standards for developing a treatment/recovery plan include, but are not limited to:

   1. (i) for residents moving directly from one program to another, or being readmitted to the same program within 60 days of discharge, the existing treatment/recovery plan may be used if there is documentation that it has been reviewed and, if necessary, updated within 14 days of transfer;
   2. (ii) if the resident is a minor, the treatment/recovery plan must also be developed in consultation with his/her parent or guardian unless the minor is being treated without parental consent as authorized by Mental Hygiene Law section 22.11.

4. (2) The treatment/recovery plan must:

   1. (i) include each diagnosis for which the resident is being treated;
   2. (ii) address resident 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 resident and primary counselor;
   3. (iii) identify a single member of the clinical staff responsible for coordinating and managing the resident's treatment who shall approve and sign (physical or electronic signature) such plan; and
   4. (iv) be reviewed and approved by the supervisor of the responsible clinical staff member within 10 days after the finalization of the treatment/recovery or service plan. If the supervisor of the responsible clinical staff member is not a qualified health professional (QHP), another QHP must be designated to sign (physical or electronic signature) the plan;

   5. (v) include schedules for the provision of all services prescribed; where a service is to be provided by any other service or facility 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, the results of the referral, and procedures for care coordination and discharge planning.

      (c) Treatment according to the treatment/recovery plan.

5. (1) The responsible clinical staff member shall ensure that the treatment/recovery plan is included in the resident record and that all treatment and services are provided in accordance with the treatment/recovery plan.

6. (2) Progress notes.

   1. (i) Progress notes shall be written, signed and dated by the responsible clinical staff member on a frequency appropriate to the element of care and consistent with policies and procedures and must include all clinical and milieu services delivered and the response of the resident to treatment. All individual and medical contacts for the purpose of assessing, diagnosing or treating the resident shall be documented in the resident record by the staff member delivering the service(s).
   2. (ii) Progress notes shall provide a chronology of the resident's progress related to the goals established in the treatment/recovery plan and be sufficient to delineate the course and results of treatment/recovery.
   3. (iii) The progress notes shall indicate the resident's participation in all significant services provided.