65D-30.0044. Plans, Progress Notes, and Summaries

(1) Treatment Plan, Treatment Plan Reviews, and Progress Notes.

(a) Treatment Plan. Each individual shall be afforded the opportunity to participate and be actively engaged in the development and subsequent review of the treatment plan. The treatment plan shall include goals and related measurable behavioral objectives to be achieved by the individual, the tasks involved in achieving those objectives, the type and frequency of services to be provided, and the expected dates of completion. The treatment plan shall be signed and dated by the person providing the service and by the individual. If the treatment plan is completed by other than a qualified professional, the treatment plan shall be reviewed, countersigned, and dated by a qualified professional within 10 calendar days of completion. In the case of Inmate Substance Abuse Programs operated by or under contract with the Department of Corrections, or the Department of Management Services, the treatment plan shall be reviewed, countersigned, and dated by a qualified professional within 30 calendar days of completion. A written treatment plan shall be completed on each individual.

1. For long-term outpatient methadone detoxification and methadone medication-assisted treatment for opioid addiction, the treatment plan shall be completed prior to or within 30 calendar days of placement.

2. For intensive inpatient treatment, the treatment plan shall be completed within three (3) calendar days of placement.

3. For residential treatment level 1, the treatment plan shall be completed prior to, or within seven (7) calendar days of placement.

4. For residential treatment levels 2, 3, and 4 day or night treatment with community housing, the treatment plan shall be completed prior to or within 15 calendar days of placement.

5. For day or night treatment, the treatment plan shall be completed prior to or within 10 calendar days of placement.

6. For intensive outpatient treatment and outpatient treatment, the treatment plan shall be completed prior to or within 30 calendar days of placement.

7. For detoxification and addictions receiving facilities, an abbreviated treatment plan, as defined in subsection 65D-30.002(1), F.A.C., shall be completed upon placement. The abbreviated treatment plan shall contain a medical plan for stabilization and detoxification, provision for education, therapeutic activities and discharge planning, and in the case of addictions receiving facilities, a psychosocial assessment.

8. For providers that are licensed for multiple program components and deliver a continuum of care, any change in level of care requires a treatment plan review or treatment plan update.

(b) Treatment Plan Reviews. Treatment plan reviews shall be completed with each individual and shall be signed and dated by the individual within 30 calendar days of the completion of the treatment plan. The treatment plan must be reviewed when clinical changes occur and as specified in subparagraphs 65D-30.0044(1)(b)1.-4., F.A.C.

1. For intensive inpatient treatment, treatment plan reviews shall be completed every seven (7) calendar days.

2. For residential treatment levels 1, 2, and 3, day or night treatment with community housing, day or night treatment, and intensive outpatient treatment, treatment plan reviews shall be completed every 30 calendar days.

3. For residential treatment level 4, treatment plan reviews shall be completed every 90 calendar days.

4. For methadone medication-assisted treatment for opioid addiction and long-term outpatient methadone detoxification, treatment plan reviews shall be completed every 90 calendar days for the first year and every 6 months thereafter.

5. For outpatient treatment, treatment plan reviews shall be completed every 90 calendar days for the first year and every six (6) months thereafter.

For all components, if the treatment plan reviews are not completed by a qualified professional, the review shall be countersigned and dated by a qualified professional within five calendar days of the review.

For all components, if the treatment plan reviews are not completed by a qualified professional, the review shall be countersigned and dated by a qualified professional within five calendar days of the review.

(c) Progress Notes. Progress notes shall be entered into the clinical record documenting an individual’s progress or lack of progress toward meeting treatment plan goals and objectives. When a single service event is documented, the progress note must be signed and dated by the person providing the service and shall include the credentials of the person who signed the notes.  When more than one (1) service event is documented, progress notes may be signed by any clinical staff member assigned to the individual. The following are requirements for recording progress notes:

1. For addictions receiving facilities, inpatient detoxification, outpatient detoxification, short-term residential methadone detoxification, short-term outpatient methadone detoxification, and intensive inpatient treatment, progress notes shall be recorded and signed at least daily;

2. For residential treatment, day or night treatment with community housing, day or night treatment, and long-term outpatient methadone detoxification, progress notes shall be recorded at least weekly;

3. For intensive outpatient treatment and outpatient treatment, progress notes shall be recorded at least weekly or, if contact occurs less than weekly, notes will be recorded according to the frequency of sessions; and

4. For methadone medication-assisted treatment for opioid addiction, progress notes shall be recorded according to the frequency of sessions and signed.

(2) Ancillary Services. This requirement applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with community housing, day or night treatment, intensive outpatient treatment, outpatient treatment, aftercare, and medication-assisted treatment for opioid addiction. Ancillary services shall be provided directly or through referral in instances where a provider cannot or does not provide certain services needed by an individual. The provision of ancillary services shall be based on individual needs as determined by the treatment plan and treatment plan reviews. In cases where individuals need to be referred for services, the provider shall use a case management approach by linking individuals to needed services and following-up on referrals. All such referrals shall be initiated and coordinated by the individual’s primary counselor or other designated clinical staff who shall serve as the individual’s case manager. A record of all such referrals for ancillary services shall be maintained in the clinical record, including whether or not a linkage occurred or documentation of efforts to confirm a linkage when confirmation was not received.

(3) Prevention Plan, Intervention Plan, and Summary Notes.

(a) Prevention Plan. For individuals receiving indicated prevention services as described in paragraph 65E-14.021(4)(v), F.A.C., a prevention plan shall be completed within 45 calendar days. Prevention plans shall include goals and objectives designed to reduce risk factors and enhance protective factors. The prevention plan shall be reviewed and updated every 60 calendar days from the date of completion of the plan. The prevention plan shall be signed and dated by staff who developed the plan and signed and dated by the individual.

(b) Intervention Plan. For individuals involved in intervention on a continuing basis, an intervention plan shall be completed within 45 calendar days. Intervention plans shall include goals and objectives designed to reduce the severity and intensity of factors associated with the onset or progression of substance use. The intervention plan shall be reviewed and updated at least every 60 days. The intervention plan shall be signed and dated by staff who developed the plan and signed and dated by the individual.

(c) Summary Notes. Summary notes shall be completed in indicated prevention and intervention services where clinical records are required. Summary notes shall contain information regarding an individual’s progress or lack of progress in meeting the conditions of the prevention or intervention plan described in paragraphs (a) and (b). Summary notes shall be entered into the individual’s clinical record at least weekly for those weeks in which services are scheduled. Each summary note shall be signed and dated by staff delivering the service.

(4) Discharge and Transfer Summaries. This requirement applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with community housing, day or night treatment, intensive outpatient treatment, outpatient treatment, medication-assisted treatment for opioid addiction, aftercare, and intervention.

(a) Discharge Summary. A written discharge summary shall be completed for individuals who complete services or who leave prior to completion of services. The discharge summary shall include a summary of the individual’s involvement in services, the reasons for discharge, and the provision of and referral to other services needed by the individual following discharge, including aftercare. The discharge summary shall be completed within 15 business days and signed and dated by a primary counselor.

(b) Transfer Summary. A transfer summary in accordance with policies and procedures shall be completed immediately for individuals who transfer from one (1) component to another within the same provider and shall be completed within 5 calendar days when transferring from one (1) provider to another. In all cases, an entry shall be made in the individual’s clinical record regarding the circumstances surrounding the transfer and that entry and transfer summary shall be signed and dated by a primary counselor within 15 days.

Rulemaking Authority 397.321(5) FS. Law Implemented 397.321, 397.410 FS. History–New 8-29-19.