SECTION 568.61. Inpatient Mental Health Treatment and Treatment Planning

(a) Inpatient mental health treatment. A hospital shall provide inpatient mental health treatment and medical care to a patient under the direction of a physician, in accordance with the highest standards accepted in medical practice, and in accordance with the patient's treatment plan and this subchapter. The treatment plan shall be appropriate to the needs and interests of the patient and be directed toward restoring and maintaining optimal levels of physical and psychological functioning.

(b) Treatment plan content within 24 hours. A hospital, in collaboration with the patient and LAR, when applicable, shall develop and implement a written treatment plan within 24 hours after the patient's admission. If the patient is unable or unwilling to collaborate with the hospital, the circumstances of such inability or unwillingness shall be documented in the patient's medical record.

(1) The treatment plan shall be based on the findings of:

(A) the physical examination described in §568.62(e)(1)(A) or (B) of this subchapter (relating to Medical Services);

(B) the psychiatric evaluation described in §568.62(f) of this subchapter; and

(C) the initial nursing assessment described in §568.63(e) of this subchapter (relating to Nursing Services).

(2) The treatment plan shall contain:

(A) a list of all diagnoses for the patient with notation as to which diagnoses will be treated at the hospital, including:

(i) at least one mental illness diagnosis;

(ii) any substance-related or addictive disorder diagnoses;

(iii) neurodevelopmental disorders; and

(iv) any other non-psychiatric conditions;

(B) a list of problems and needs that are to be addressed during the patient's hospitalization;

(C) a description of all treatment interventions intended to address the patient's problems and needs, including the medications prescribed and the symptoms each medication is intended to address;

(D) identification of any additional assessments and evaluations to be conducted, which shall include the social assessment described in §568.64(d) of this subchapter (relating to Social Services);

(E) identification of the level of monitoring assigned to the patient; and

(F) the rationale for the treatment interventions and any enhanced levels of monitoring described in subparagraphs (C) and (E) of this paragraph.

(c) Treatment plan content within 72 hours.

(1) Within 72 hours of the patient's admission the hospital shall:

(A) establish an interdisciplinary treatment team (IDT) for a patient;

(B) conduct the social assessment described in subsection (b)(2)(D) of this section;

(C) initiate referrals for any additional assessments and evaluations identified in accordance with subsection (b)(2)(D) of this section;

(D) review the content of the treatment plan required by subsection (b)(2) of this section, and revise the plan, if necessary, based on the findings of the social assessment or as otherwise clinically indicated; and

(E) add to the treatment plan:

(i) a description of the goals of the patient relating to the problems and needs listed in accordance with subsection (b)(2)(B) of this section;

(ii) the specific treatment modalities for each treatment intervention by type and frequency;

(iii) the IDT member responsible for providing or ensuring the provision of each treatment intervention;

(iv) the time frames and measures to evaluate progress of the treatment plan toward meeting the goals of the patient;

(v) a description of the clinical criteria for the patient to be discharged; and

(vi) a description of the recommended services and supports needed by the patient after discharge as required by §568.81(a)(3)(A) of this chapter (relating to Discharge Planning).

(2) The treatment plan shall be signed by all members of the IDT. If the patient is unable or unwilling to sign the treatment plan, the reason for or circumstances of such inability or unwillingness shall be documented in the patient's medical record.

(d) Treatment plan review. In addition to the review required by subsection (c)(1)(D) of this section, the treatment plan shall be reviewed, and its effectiveness evaluated:

(1) when there is a significant change in the patient's condition or diagnosis or as otherwise clinically indicated:

(2) in accordance with the time frames and measures described in the treatment plan; and

(3) upon request by the patient or the patient's legally authorized representative.

(e) Treatment plan revision. In addition to a revision required by subsection (c)(1)(D) of this section, the treatment plan shall be revised, if necessary, based on the findings of any assessment, reassessment, evaluation, or re-evaluation, or as otherwise clinically indicated.

(f) Documentation of treatment plan review and revisions. A treatment plan review and revision shall be signed by all members of the IDT. If the patient is unable or unwilling to sign the review or revision, the reason for or circumstances of such inability or unwillingness shall be documented in the patient's medical record.

Source Note: The provisions of this §568.61 adopted to be effective May 27, 2021, 46 TexReg 3276