SECTION 450:27-7-42. Behavioral health service plan; documentation

(a)   The service plan is developed and finalized with the active participation of the consumer and a support person or advocate if requested by the consumer. In the case of children under the age of 18, it is performed with the participation of the parent or guardian and the child as age and developmentally appropriate. The service plan shall provide the formation of measurable service objectives and reflect ongoing changes in goals and objectives based upon consumer's progress or preference or the identification of new needs, challenges and problems.

(b)   The service plan shall completed by a LBHP or licensure candidate and be based on information obtained in the mental health assessment, other information provided on behalf of the consumer, and includes the evaluation of the assessment information by the clinician and the consumer.

(c)   For adults, the service plan must be focused on recovery. For children the plan should address school and education concerns and assisting the family in caring for the child in the least restrictive level of care.

(d)   Service plans must be completed within six (6) treatment sessions and include:

(1)   Consumer strengths, needs, abilities, and preferences;

(2)   Identified presenting challenges, needs, and diagnosis;

(3)   Goals for treatment with specific, measurable, attainable, realistic, and time-limited objectives;

(4)   Type and frequency of services to be provided;

(5)   Description of consumer's involvement in, and response to, the service plan;

(6)   The service provider who will be rendering the services identified in the service plan; and

(7)   Discharge criteria that are individualized for each consumer.

(e)   Service plan updates should occur at a minimum of every 6 months during which services are provided and include the following:

(1)   Progress on previous service plan goals and/or objectives;

(2)   A statement documenting a review of the current service plan and an explanation if no changes are to be made to the service plan;

(3)   Change in goals and/or objectives based upon consumer's progress or identification of new needs and challenges;

(4)   Change in frequency and/or type of services provided;

(5)   Change in staff who will be responsible for providing services on the plan; and

(6)   Change in discharge criteria.

(f)   Service plans, both comprehensive and update, must include dated signatures for the consumer (if over age 14), the parent/guardian (if under age 18 or otherwise applicable), and the primary service practitioner. Signatures must be obtained after the service plan is completed.

(g)   Compliance with 450:27-7-42 shall be determined by a review of the clinical records, policies and procedures, and interviews with staff and consumers, and other agency documentation.

[Source: Added at 29 Ok Reg 663, eff 7-1-12; Amended at 35 Ok Reg 1854, eff 10-1-18; Amended at 36 Ok Reg 1157, eff 11-1-19]