After a guardianship program or one of its members is appointed as a guardian of the person, the guardianship program will develop a care plan to address the client's personal needs.
  (1) Guardian of the Person Care Plans. The care plan should address the powers, duties, and responsibilities given to the guardian of the person by the court's order appointing the guardian. If the court's order states that the guardian of the person has full authority, the care plan should address the powers, duties, and responsibilities given to the guardian of the person by section 767, Probate Code, Powers and Duties of Guardians of the Person, and other applicable sections of Chapter 13, Probate Code, concerning guardianships. The care plan may also include the following:
    (A) monitoring services being provided to the client;
    (B) providing appropriate clothing for the client;
    (C) arranging for medical care, dental care, psychiatric care, and rehabilitation services as necessary;
    (D) arranging for education and/or employment opportunities when appropriate;
    (E) monitoring the nutrition of the client;
    (F) obtaining safe and secure housing; and
    (G) obtaining needed public benefits, if there is no guardian of the estate or other person charged with securing those benefits.
  (2) Health Care Decisions. A guardianship program will develop a policy that generally describes the types of decisions that can be made by the guardian independently, the types of decisions that should be made only on the advice of two physicians or a psychologist licensed in this state or certified by the Texas Department of Mental Health and Mental Retardation, the types of decisions that should be made only with peer review, and the types of decisions that should be made only after obtaining an order from the court.
  (3) Personal Visits. A guardianship program will establish a policy concerning the frequency of personal visits to be made by the guardian or the guardian's representative to the guardianship client. These periodic visits should include personal interaction with the client, if possible, monitoring for signs of abuse or neglect and, if applicable, checking facility charts and consulting with facility staff or other caregivers.
  (4) Client Files. A guardianship program will maintain a file on each client that includes intake information, a current copy of the personal and/or financial care plan, a copy of any court orders or Letters of Guardianship, and a case note concerning client activities and concerns.
  (5) End of Life Decisions. A guardianship program will include in its care plan whether the client has a Do Not Resuscitate document or Directive to Physicians and whether the client has ever expressed a preference regarding the use of extraordinary life sustaining measures. A guardianship program shall consult with legal counsel and the judges of courts with guardianship jurisdiction in its service area to develop a policy regarding end of life decisions. This policy should be communicated to all employees and volunteers of the guardianship program.

Source Note: The provisions of this §381.365 adopted to be effective November 21, 2002, 27 TexReg 10719