Pa. Code 5200.31

Treatment planning

This section requires that a mental health professional (or supervised mental health worker) complete a comprehensive assessment for each individual before developing an initial treatment plan within 30 days of intake. The treatment plan must specify goals, objectives, modalities, expected duration, and responsible parties, and must be developed with active client involvement; for children under 14, parental/guardian consent and participation are required. Plans must be reviewed and updated at defined intervals—every 30 days for involuntary outpatient commitments and at least every 180 days for voluntary clients—and reviewed annually by a psychiatrist or advanced practice professional. All treatment services must align with the plan, and the plan and updates must be maintained in the individual record.

55 Pa. Code § 5200.31 - Treatment planning 

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(a)
 For
 each individual receiving services, a mental health professional or mental
 health worker under the supervision of a mental health professional shall
 complete an assessment of the behavioral health, medical, psychological,
 social, vocational, educational and other factors important to the individual
 prior to the development of the initial comprehensive treatment plan.

(b)
 An initial comprehensive treatment plan
 shall be developed, reviewed and approved within 30 days of the intake and
 assessment with every individual who continues to participate in the treatment
 process in accordance with the following: 
(1)

 The mental health professional or the mental health worker under the
 supervision of the mental health professional and the individual receiving
 services shall develop, sign and date the initial treatment plan.

(2)
 If the individual is receiving
 psychotherapy and other clinical services, the psychiatrist or advanced
 practice professional shall review, approve, sign and date the initial
 treatment plan.

(3)
 If the
 individual is receiving medication management services only, the psychiatrist,
 physician, certified registered nurse practitioner or physician assistant
 responsible for prescribing and monitoring the use of the medication shall
 review, approve, sign and date the initial treatment plan.

(4)
 For individuals under an involuntary
 outpatient commitment, the mental health professional or advanced practice
 professional providing services and the individual shall develop, review, sign
 and date the initial treatment plan. The treatment plan shall be reviewed and
 signed by the psychiatrist as part of the oversight of the treatment services
 provided.

(c)
 The
 treatment plan must be based upon the assessment and shall: 
 
(1)
 Specify the goals and objectives of the
 plan, prescribe an integrated program of therapeutic activities and
 experiences, specify the modalities to be utilized and the expected duration of
 services and the person or persons responsible for carrying out the
 plan.

(2)
 Be directed at specific
 outcomes and connect these outcomes with the treatment modalities and
 activities proposed.

(3)
 Be
 developed with the active involvement of the individual receiving services and
 shall include strengths and needs. The treatment plan may also address
 individual preferences, resilience and functioning.

(4)
 For children and adolescents under 14
 years of age, be developed and implemented with the consent of parents or
 guardians and include their participation in treatment as required by statute
 or regulation.

(5)
 Specify an
 individualized treatment program for each individual, which shall include
 clinically appropriate services such as psychiatric evaluation and diagnosis,
 psychological evaluation, individual, group and family psychotherapy, behavior
 therapy, crisis intervention services, medication evaluation and management,
 and similar services.

(d)

 The treatment plan shall be reviewed and updated throughout the duration of
 treatment as follows: 
(1)
 For individuals
 under an involuntary outpatient commitment, the treatment plan shall be
 reviewed and updated every 30 days by the mental health professional or
 advanced practice professional providing treatment services and the individual
 receiving services. The treatment plan update shall be reviewed and signed by
 the psychiatrist as part of the oversight of treatment services
 provided.

(2)
 For individuals
 voluntarily receiving treatment, the treatment plan shall be reviewed and
 updated at a minimum of every 180 days by the mental health professional,
 mental health worker under the supervision of a mental health professional,
 certified registered nurse practitioner or physician assistant providing
 treatment services and the individual receiving services.

(3)
 The treatment plan update shall be signed
 and dated by the mental health professional, mental health worker under the
 supervision of a mental health professional, certified registered nurse
 practitioner or physician assistant providing treatment services.

(4)
 The mental health professional or mental
 health worker shall request the individual to sign and date the treatment plan
 update. In the event the individual does not sign the treatment plan update,
 the mental health professional or mental health worker shall document the
 request in the record.

(e)

 All treatment services shall be provided in accordance with the identified
 goals in the treatment plan and updates.

(f)
 The treatment plan and updates shall be
 kept in the individual record.

(g)

 The treatment plan shall be reviewed on an annual basis by the psychiatrist or
 advanced practice professional throughout the course of treatment from the
 psychiatric outpatient clinic and documented in the individual
 record.

Notes

55

 Pa. Code §
 
5200.31

The
 provisions of this § 5200.31 amended October 11, 2019, effective
 
10/12/2019
, 49 Pa.B.
 5943.

The provisions of this § 5200.31 amended under section
 1021 of the Human Services Code (
62 P.S. §
 
1021
);
 sections 105 and 112 of the Mental Health Procedures Act (
50 P.S. §§
 
7105
 and
 
7112
); and section 201(2) of
 the Mental Health and Intellectual Disability Act of 1966 (
50 P.S. §
 
4201(2)
).

This section cited in 55 Pa. Code §
 
5200.52
 (relating to treatment
 planning).

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