(1) Patients shall have the opportunity to participate in the preparation of their own treatment and discharge plans at receiving and treatment facilities and by service providers. In instances when the person refuses or is unable to participate in such planning, such refusal or inability shall be documented in the person’s clinical record.
    (2) Comprehensive service assessment and treatment planning, including discharge planning, shall begin the day of admission and shall also include the person’s case manager if any, the person’s friends, family, significant others, or guardian, as desired by the person. If the person has a court appointed guardian, the guardian shall be included in the service assessment and treatment planning. Obtaining legal consent for treatment, assessment and planning protocols shall also include the following:
    (a) How any advance directives will be obtained and their provisions addressed and how consent for treatment will be expeditiously obtained for any person unable to provide consent;
    (b) Completion of necessary diagnostic testing and the integration of the results and interpretations from those tests. The results and interpretation of the results shall be reviewed with the person;
    (c) The development of treatment goals specifying the factors and symptomology precipitating admission and addressing their resolution or mitigation;
    (d) The development of a goal within an individualized treatment plan, including the individual’s strengths and weaknesses, that addresses each of the following: living arrangements, social supports, financial supports, and health, including mental health. Goals shall be inclusive of the person’s choices and preferences and utilize available natural social supports such as family, friends, and peer support group meetings and social activities;
    (e) Objectives for implementing each goal shall list the actions needed to obtain the goal, and shall be stated in terms of outcomes that are observable, measurable, and time-limited;
    (f) Progress notes shall be dated and shall address each objective in relation to the goal, describing the corresponding progress, or lack of progress being made. Progress note entries and the name and title of writer must be clearly legible;
    (g) Periodic reviews shall be comprehensive, include the person, and shall be the basis for major adjustments to goals and objectives. Frequency of periodic reviews shall be determined considering the degree to which the care provided is acute care and the projected length of stay of the person;
    (h) Progress note observations, participation by the person, rehabilitative and social services, and medication changes shall reflect an integrated approach to treatment;
    (i) Facilities shall update the treatment plan, including the physician summary, at least every 30 days during the time a person is in a receiving or treatment facility except that persons retained for longer than 24 months shall have updates at least every 60 days;
    (j) The clinical record shall comprehensively document the person’s care and treatment, including injuries sustained and all uses of emergency treatment orders; and,
    (k) Persons who will have a continued involuntary outpatient placement hearing pursuant to Florida Statutes § 394.4655(7), or continued involuntary inpatient placement hearing pursuant to Florida Statutes § 394.467(7), shall be provided with comprehensive re-assessments, the results of which shall be available at the hearing.
    (3) The physical examination required to be provided to each person who remains at a receiving or treatment facility for more than 12 hours must include:
    (a) A determination of whether the person is medically stable; and,
    (b) A determination that abnormalities of thought, mood, or behavior due to non-psychiatric causes have been ruled out.
Rulemaking Authority 394.457(5), 394.46715 FS. Law Implemented 394.459(2), 394.4655(7), 394.467(7) FS. History-New 11-29-98, Amended 4-4-05.