CMS SOM App. FC, Tag M0244

All CMHC care and

services furnished to clients must be consistent with an individualized, written, active

treatment plan that is established by the CMHC interdisciplinary treatment team, the

client, and the client’s primary care giver(s), in accordance with the client’s recovery

goals and preferences, within 7 working days of admission to the CMHC. The CMHC

must ensure that each client and the client’s primary caregiver(s), as applicable, receive

education and training provided by the CMHC that are consistent with the client’s and

caregiver’s responsibilities as identified in the active treatment plan.

Interpretive Guidelines §485.916(b)

The client’s medical record includes documentation that the interdisciplinary treatment

team, the client, and his/her primary care giver(s) (such as family or guardian)

collaborated in the development of the treatment plan. The client and/or primary care

giver(s) must be invited to be a part of the treatment planning team. If it is not possible

to receive input from the client or primary care giver(s) prior to or during the planning

meeting, the team must discuss the plan with them and receive their concurrence. If the

client or primary care giver(s) does not respond to requests for concurrence, the team

proceeds with the plan and documents all attempts to receive concurrence.

There should be documentation in the client’s medical record that the facility met face to

face, by phone or other electronic medium with the client and caregiver(s), as applicable,

to discuss their role in the client’s care, and that the client and caregiver(s) accepted,

agreed, and understood their role in implementing the active treatment plan.

If the client or caregiver(s) does not agree to participate in the development of the

treatment plan, there should be documentation of attempts by the CMHC to encourage

participation.