SOP 508.21: Treatment Plans

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Treatment Plans|Policy Name:Treatment Plans|Policy Name:Treatment Plans|
|Policy Number: 508.21|Effective Date: 9/23/2020|Page Number: 1 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

All offenders receiving mental health (MH) services will have a current
individualized treatment plan written by their primary care provider. This procedure
is applicable to all Georgia Department of Corrections (GDC) with a mental health
mission.

II. Authority:

A. O.C.G.A. §§37-3-1 and 37-3-85;

B. Ga. Comp. R. & Regs. 125-4-5-.02 (b);

C. ACA Standards: 5-ACI-6A-07 (ref. 4-4350), 5-ACI-6A-32 (ref. 4-4371

Mandatory), 5-ACI-6B-02 (ref. 4-4381 Mandatory), 4-ALDF-4C-07, 4-ALDF
4C-30 (Mandatory), and 4-ALDF-5A-07; and

D. National Commission of Correctional Health Care, Standards for Health Services

in Prisons, January 2014.

III. Definitions:

A. Initial Treatment Plan (ITP) - The Initial Treatment Plan (M50-01-01) is

written on the Initial Treatment Plan Form identifying the presenting problems,
goals and treatment strategies.

B. Comprehensive Treatment Plan (CTP) - This plan is written on the

Comprehensive Treatment Plan Form (M50-01-02) that includes identifying
information, diagnoses, strengths and weaknesses, justification for level of care
(utilization review), specific problems, intervention strategies, person responsible
for the intervention, operational goals, the date treatment began, the dates goals
were achieved and/or the dates strategies or goals were changed.

C. Treatment Plan Reviews (TPR) - The Treatment Plan Review is written on the

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Treatment Plans|Policy Name:Treatment Plans|Policy Name:Treatment Plans|
|Policy Number: 508.21|Effective Date: 9/23/2020|Page Number: 2 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

Treatment Plan Review Form (M50-01-03) that includes identifying information,
diagnoses, justification for level of care (utilization review), and summary of
progress and changes in goals and/or interventions.

D. Primary Mental Health Care Provider - The primary care provider is the

offender's mental health counselor or mental health technician who provides and
coordinates treatment. The primary care provider could be a mental health
counselor, mental health technician or a behavior specialist, if credentialed to
provide those services.

E. Clinical Supervisor - A licensed psychologist who clinically supervises

unlicensed primary mental health care providers.

F. Treatment Team - May consist of but is not limited to the Mental Health Unit

Manager, Psychiatrists, Advanced Practice Registered Nurse (APRNs),
Psychologists, Mental Health Counselors, Mental Health Technicians, Behavior
Specialists, Mental Health Nurses, Activity Therapists, Teachers, Chaplains, and
Multi-functional Correctional Officers (MFCO) or other Correctional Officers.

IV. Statement of Policy and Applicable Procedures:

A. Offenders are assigned to the mental health caseload based on the mental health

evaluation process which includes completion of the Initial Treatment Plan (ITP)
(Attachment 1, form M50-01-01). A copy of the evaluation is given to the
mental health unit manager who assigns the case to a primary mental health
care provider based on the evaluation.

B. In a diagnostic facility, the Initial Treatment Plan will be followed for offenders

who remain at the facility up to 60 days. A Comprehensive Treatment Plan
(Attachment 2, form M50-01-02) shall be completed at 60 days from placement
on the mental health caseload for offenders who remain at the facility.

C. In a non-diagnostic facility, the primary mental health care provider will write a

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Treatment Plans|Policy Name:Treatment Plans|Policy Name:Treatment Plans|
|Policy Number: 508.21|Effective Date: 9/23/2020|Page Number: 3 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

Comprehensive Treatment Plan (Attachment 2, form M50-01-02) within 30 days
of placement on the mental health caseload. Comprehensive Treatment Plans
(Attachment 2, form M50-01-02) will be completed within 30 days after
receiving an offender from a diagnostic facility.

D. Comprehensive Treatment Plans (Attachment 2, form M50-01-02) will not be

required for residential substance abuse treatment (RSAT) or probation detention
center (PDC) detainees who have a maximum of 90 days to serve. The Initial
Treatment Plan (ITP) (Attachment 1, form M50-01-01) will be the plan used for
the detainee’s stay in the program and must include discharge planning.
Comprehensive Treatment Plans (Attachment 2, form M50-01-02) are completed
within 30 days for detainees who have more than 90 days to serve. This time
frame also applies to detainees at the integrated treatment facilities (ITF).

E. The offender and appropriate staff will participate in the development of the

Comprehensive Treatment Plan (Attachment 2, form M50-01-02), which is based
on the diagnoses documented on the Diagnosis List (508.09 Mental Health
Records, Attachment 5, form M20-01-05) and secondary functional problems. The
Comprehensive Treatment Plan (Attachment 2, form M50-01-02) is placed in the
mental health file, section 2. Clinical decisions are the sole province of the
responsible mental health Treatment Team and are not countermanded by nonclinicians.

F. The Comprehensive Treatment Plan (Attachment 2, form M50-01-02) shall be

reviewed and signed by the offender. The Comprehensive Treatment Plan
(Attachment 2, form M50-01-02) shall be reviewed and signed by the primary care
provider and by appropriate Treatment Team members and placed in section 2 of
the mental health file. Problems, goals, and intervention strategies shall be
appropriately identified. Group treatment placement as well as class of
medication, if prescribed, is included on the treatment plan as an intervention
strategy as well as class of medication, if prescribed, are to be included on the
treatment plan as intervention strategies.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Treatment Plans|Policy Name:Treatment Plans|Policy Name:Treatment Plans|
|Policy Number: 508.21|Effective Date: 9/23/2020|Page Number: 4 of 4|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

G. The diagnoses and level of care on the Comprehensive Treatment Plan

(Attachment 2, form M50-01-02) must match the diagnoses and level of care on
the Diagnosis List (508.09 Attachment 5, form M20-01-05) and in Scribe. The
Comprehensive Treatment Plan (Attachment 2, form M50-01-02) shall be
updated or rewritten as necessary if the diagnosis or level of care changes.

H. The Comprehensive Treatment Plan Review (Attachment 3, form M50-01-03)

shall be completed by the primary care provider within six months of the
Comprehensive Treatment Plan (Attachment 2, form M50-01-02). The staff
psychologist will review and sign the completed Comprehensive Treatment Plan
within 30 days prior to the due date. A Comprehensive Treatment Plan Review
(Attachment 3, form M50-01-03) will be completed every four (4) months for
Level III and Level IV offenders. It is signed by appropriate Treatment Team
members and placed in section 2 of the clinical file.

I. A new Comprehensive Treatment Plan (Attachment 2, form M50-01-02) is

developed at least every 12 months. The mental health unit manager or a
designated counselor in the absence of a mental health unit manager shall
monitor this with a treatment plan tickler file.

V. Attachments:

Attachment 1: Initial Treatment Plan (M50-01-01)
Attachment 2: Comprehensive Treatment Plan (M50-01-02)
Attachment 3: Comprehensive Treatment Plan Review (M50-01-03)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1, 2 and 3, shall be placed in the offender’s mental
health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record
and retained for 10 years.