Pa. Code 5100.15

Contents of treatment plan

This section specifies the required contents of a comprehensive individualized treatment plan for patients receiving mental health treatment under Pennsylvania's mental health procedures regulations. The plan must be developed collaboratively with the patient and an interdisciplinary team, based on a full diagnostic evaluation, and must set forth treatment objectives and an integrated program of therapies. It must document consideration of less restrictive alternatives, be written in plain language, and be retained in the patient's medical record in a form approved by the Deputy Secretary of Mental Health.

55 Pa. Code § 5100.15 - Contents of treatment plan 

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(a)
 A
 comprehensive individualized plan of treatment shall: 
 
(1)
 Be formulated to the extent feasible,
 with the consultation of the patient. When appropriate to the patient's age, or
 with the patient's consent, his family, personal guardian, or appropriate other
 persons should be consulted about the plan.

(2)
 Be based upon diagnostic evaluation which
 includes examination of the medical, psychological, social, cultural,
 behavorial, familial, educational, vocational, and developmental aspects of the
 patient's situation.

(3)
 Set forth
 treatment objectives and prescribe an integrated program of therapies,
 activities, experiences, and appropriate education designed to meet these
 objectives.

(4)
 Result from the
 collaborative recommendation of the patient's interdisciplinary treatment
 team.

(5)
 Be maintained and updated
 with progress notes, and be retained in the patient's medical record on a form
 developed by the facility and approved by the Deputy Secretary of Mental
 Health, as part of the licensing approval process.

(b)
 The treatment plan shall indicate what
 less restrictive alternatives were considered and why they were not utilized.
 If the plan provides for restraints, the basis for the necessity for such
 restraints must be stated in the plan under Chapter 13 (relating to use of
 restraints in treating patients/residents).

(c)
 Individual treatment plans shall be
 written in terms easily explainable to the lay person and a copy of the current
 treatment plan shall be available for review by the person in
 treatment.

(d)
 When the most
 appropriate form of treatment for the individual is not available or is too
 expensive to be feasible, that fact shall be noted on the treatment plan
 form.

Notes

55

 Pa. Code §
 
5100.15

This section cited in 55 Pa. Code §
 
5100.4
 (relating to scope); and 55
 Pa. Code §
 
5100.75
 (relating to physical
 examination and formulation of individualized treatment
 plan).

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