(a) The provider shall work with the client to develop and implement an individualized, written treatment plan that identifies the services and support needed to address the problems and needs identified in the assessment. The client's parent(s) or guardian(s) shall also be involved unless such involvement is not possible or appropriate. In such instances, the client record shall include documentation explaining why the involvement of the parent(s) or guardian(s) was not possible or appropriate.
  (1) When the client needs services not offered by the treatment program, appropriate referrals shall be made and documented in the client's record.
  (2) The client record shall contain justification when identified needs are temporarily deferred or not addressed during treatment.
(b) The treatment plan shall include goals, objectives, and strategies.
  (1) Goals shall be based on the client's problems/needs, strengths, and preferences.
  (2) Objectives shall be individualized, realistic, measurable, time-specific, appropriate to the level of treatment, and clearly stated in behavioral terms.
  (3) Strategies shall describe the type and frequency of the specific services and interventions needed to help the client achieve the identified goals and shall be appropriate to the intensity level of the treatment program in which the client is receiving treatment.
(c) The treatment plan shall identify discharge criteria and include initial plans for discharge.
(d) The treatment plan shall include a projected length of stay in the treatment program.
(e) The treatment plan shall identify the client's primary provider and must be dated and signed by the client and the provider. When the treatment plan is prepared by a provider who is not a QCC, a QCC must review and sign the treatment plan.
(f) The treatment plan shall be completed and filed in the client record no later than seven calendar days after admission.
(g) The primary provider shall meet with the client to review and update the treatment plan at appropriate intervals, as defined in writing by the treatment program. In non-residential treatment programs, treatment plans must be reviewed no less frequently than midway through the projected duration of treatment. In residential treatment programs, treatment plans must be reviewed no less frequently than monthly.
(h) The treatment plan review shall include:
  (1) an evaluation of the client's progress toward each goal and objective;
  (2) revision of the goals and objectives, as necessary; and
  (3) justification of continued length of stay in the treatment program.
(i) Treatment plan reviews must be dated and signed by the client, the provider, and, if applicable, the supervising QCC.
(j) When a client's intensity of service is changed, the client record must contain:
  (1) clear documentation of the decision, signed by a QCC, including the rationale and the effective date;
  (2) a revised treatment plan; and
  (3) documentation of coordination activities with the receiving provider, if there is a different provider.
(k) Treatment program personnel shall document all substance use disorder services in the client record within 72 hours, including the date, nature, and duration of the contact and the signature or electronic authentication of the provider.
  (1) Education, life skills training, and group counseling notes must also include the topics/issues addressed.
  (2) Individual counseling notes must include the goals addressed, clinical observations, and new issues or needs identified during the session.

Source Note: The provisions of this §353.308 adopted to be effective October 1, 2021, 46 TexReg 6408