(a) Screening and assessment. When a screening determines an assessment is necessary, an integrated assessment must be conducted to consider relevant past and current medical, psychiatric, and substance use information, including:
  (1) information from the individual (and LAR on the individual's behalf) regarding the individual's strengths, needs, natural supports, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;
  (2) the needs and desire of the individual for family member involvement in treatment and services if the individual is an adult without an LAR; and
  (3) recommendations and conclusions regarding treatment needs and eligibility for services for individuals.
(b) Treatment plan development.
  (1) The individual (and LAR on the individual's behalf, if applicable) must be involved in all aspects of planning the individual's treatment. If the individual has requested the involvement of a family member, then the provider must attempt to involve the family member in all aspects of planning the individual's treatment.
  (2) The treatment plan must identify services to be provided and must include measurable outcomes that address COPSD.
  (3) The treatment plan must identify the LAR's or family members' need for education and support services related to the individual's mental illness and substance abuse and a method to facilitate the LAR's or family members' receipt of the needed education and support services.
  (4) The individual, LAR, and, if requested, family member, must be given a copy of the treatment plan.
(c) Treatment plan review. Each individual's treatment plan must be reviewed in accordance with DSHS-defined timeframes and the review must be documented.
(d) Progress notes. The medical record notes must contain a description of the individual's progress towards goals identified in the treatment plan, as well as other clinically significant activities or events.
(e) Episode of care summary. Upon discharge or transfer of an individual from one entity to another, the individual's medical record must identify the services provided according to this subchapter and the items referenced in §412.322 (relating to Provider Responsibilities for Treatment Planning and Service Authorization) of Chapter 412, Subchapter G of this title, governing Mental Health Community Services Standards.

Source Note: The provisions of this §306.19 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467