1. (1) An individual Plan of Care must be developed and implemented for each service recipient. The individual Plan of Care (POC) must be based on initial history and on-going assessment of the service recipient’s needs and strengths and must be completed within seventy-two (72) hours of admission.

2. (2) Documentation of the POC and of its implementation must be kept in the service recipient record and must include the following:

   1. (a) The service recipient’s name on the POC;
   2. (b) The date of development of the POC;
   3. (c) Individual problems specified in the POC which are to be addressed within the particular service/program component, including treatment and educational components;
   4. (d) Individual objectives which are related to specified problems identified in the POC and which are to be addressed by the particular service/program component;
   5. (e) Interventions and staff responsible for addressing goals and objectives in the POC;
   6. (f) Signatures of the staff providing the services;
   7. (g) Documentation of participation of service recipient and parent/guardian/legal custodian or conservator where appropriate, in the treatment planning process; if any of the parties refuse to participate, reasons for refusal must be documented. FOR CHILDREN AND YOUTH
   8. (h) Standardized diagnostic formulation(s), [including, but not limited to, the current Diagnostic and Statistical Manual (DSM) Axes I-V and/or ICD-9] where appropriate, and assessment documentation on file which is updated as recommended by POC team;
   9. (i) Planned frequency of treatment contacts;
   10. (j) A plan for family involvement in the service recipient’s treatment.

3. (3) A review of the POC must occur at least every thirty (30) days or upon completion of the stated goals and objectives and must include the following documentation:

   1. (a) Dated signatures of appropriate staff, and
   2. (b) An assessment of progress toward each treatment goal and / or objective with revisions as indicated, and
   3. (c) A statement of justification for the level of service(s) needed, including suitability for treatment in a less restrictive environment and continued services.

Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 32-2-302, and 33-2-404. Administrative History: Original rule filed June 29, 2004; effective September 12, 2004.