Each client must have an individual treatment plan developed by an alcohol and drug counselor within seven days of service initiation for a residential program and within three sessions for all other programs. The client must have active, direct involvement in selecting the anticipated outcomes of the treatment process and developing the treatment plan. The individual treatment plan must be signed by the client and the alcohol and drug counselor and document the client's involvement in the development of the plan. The plan may be a continuation of the initial services plan required in section 245G.04. Treatment planning must include ongoing assessment of client needs. An individual treatment plan must be updated based on new information gathered about the client's condition and on whether methods identified have the intended effect. A change to the plan must be signed by the client and the alcohol and drug counselor. The plan must provide for the involvement of the client's family and people selected by the client as important to the success of treatment at the earliest opportunity, consistent with the client's treatment needs and written consent.
An individual treatment plan must be recorded in the six dimensions listed in section 245G.05, subdivision 2, paragraph (c), must address each issue identified in the assessment summary, prioritized according to the client's needs and focus, and must include:
(1) specific methods to address each identified need, including amount, frequency, and anticipated duration of treatment service. The methods must be appropriate to the client's language, reading skills, cultural background, and strengths;
(2) resources to refer the client to when the client's needs are to be addressed concurrently by another provider; and
(3) goals the client must reach to complete treatment and terminate services.
(a) A review of all treatment services must be documented weekly and include a review of:
(1) care coordination activities;
(2) medical and other appointments the client attended;
(3) issues related to medications that are not documented in the medication administration record; and
(4) issues related to attendance for treatment services, including the reason for any client absence from a treatment service.
(b) A note must be entered immediately following any significant event. A significant event is an event that impacts the client's relationship with other clients, staff, the client's family, or the client's treatment plan.
(c) A treatment plan review must be entered in a client's file weekly or after each treatment service, whichever is less frequent, by the staff member providing the service. The review must indicate the span of time covered by the review and each of the six dimensions listed in section 245G.05, subdivision 2, paragraph (c). The review must:
(1) indicate the date, type, and amount of each treatment service provided and the client's response to each service;
(2) address each goal in the treatment plan and whether the methods to address the goals are effective;
(3) include monitoring of any physical and mental health problems;
(4) document the participation of others;
(5) document staff recommendations for changes in the methods identified in the treatment plan and whether the client agrees with the change; and
(6) include a review and evaluation of the individual abuse prevention plan according to section 245A.65.
(d) Each entry in a client's record must be accurate, legible, signed, and dated. A late entry must be clearly labeled "late entry." A correction to an entry must be made in a way in which the original entry can still be read.
(a) An alcohol and drug counselor must write a discharge summary for each client. The summary must be completed within five days of the client's service termination or within five days from the client's or program's decision to terminate services, whichever is earlier.
(b) The service discharge summary must be recorded in the six dimensions listed in section 245G.05, subdivision 2, paragraph (c), and include the following information:
(1) the client's issues, strengths, and needs while participating in treatment, including services provided;
(2) the client's progress toward achieving each goal identified in the individual treatment plan;
(3) a risk description according to section 245G.05; and
(4) the reasons for and circumstances of service termination. If a program discharges a client at staff request, the reason for discharge and the procedure followed for the decision to discharge must be documented and comply with the program's policies on staff-initiated client discharge. If a client is discharged at staff request, the program must give the client crisis and other referrals appropriate for the client's needs and offer assistance to the client to access the services.
(c) For a client who successfully completes treatment, the summary must also include:
(1) the client's living arrangements at service termination;
(2) continuing care recommendations, including transitions between more or less intense services, or more frequent to less frequent services, and referrals made with specific attention to continuity of care for mental health, as needed;
(3) service termination diagnosis; and
(4) the client's prognosis.