(1) A transitional living facility shall develop a comprehensive treatment plan for each client as soon as practicable but no later than 30 days after the initial comprehensive treatment plan is developed. The comprehensive treatment plan must be developed by an interdisciplinary team consisting of the case manager, the program director, the advanced practice registered nurse, and appropriate therapists. The client or, if appropriate, the client’s representative must be included in developing the comprehensive treatment plan. The comprehensive treatment plan must be reviewed and updated if the client fails to meet projected improvements outlined in the plan or if a significant change in the client’s condition occurs. The comprehensive treatment plan must be reviewed and updated at least once monthly.
(2) The comprehensive treatment plan must include:(a) Orders obtained from the physician, physician assistant, or advanced practice registered nurse and the client’s diagnosis, medical history, physical examination, and rehabilitative or restorative needs.
(b) A preliminary nursing evaluation, including orders for immediate care provided by the physician, physician assistant, or advanced practice registered nurse, which shall be completed when the client is admitted.
(c) A comprehensive, accurate, reproducible, and standardized assessment of the client’s functional capability; the treatments designed to achieve skills, behaviors, and other conditions necessary for the client to return to the community; and specific measurable goals.
(d) Steps necessary for the client to achieve transition into the community and estimated length of time to achieve those goals.
(3) The client or, if appropriate, the client’s representative must consent to the continued treatment at the transitional living facility. Consent may be for a period of up to 6 months. If such consent is not given, the transitional living facility shall discharge the client as soon as practicable.
(4) A client must receive the professional program services needed to implement the client’s comprehensive treatment plan.
(5) The licensee must employ qualified professional staff to carry out and monitor the various professional interventions in accordance with the stated goals and objectives of the client’s comprehensive treatment plan.
(6) A client must receive a continuous treatment program that includes appropriate, consistent implementation of specialized and general training, treatment, health services, and related services and that is directed toward:(a) The acquisition of the behaviors and skills necessary for the client to function with as much self-determination and independence as possible.
(b) The prevention or deceleration of regression or loss of current optimal functional status.
(c) The management of behavioral issues that preclude independent functioning in the community.
