OAR 410-170-0070: BRS Service Planning

(1) Initial Service Plan (ISP): (a) A BRS contractor that provides services and placement-related activities in a Shelter, Independent Living program, Enhanced Structure Independent Living program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Basic Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support program shall, and require that its BRS providers: (A) Ensure that a social service staff member completes a written ISP within two business days of the BRS client’s admission to its program; (B) Provide an opportunity for the following individuals to participate in developing the BRS client’s ISP, including but not limited to the BRS client, the BRS client’s family, fictive kin, social service staff, the BRS client’s caseworker, and any other significant individuals involved with the BRS client; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the ISP; (D) Obtain written approval of the ISP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and (E) Provide the services identified in the ISP during the first 45 days in the BRS provider’s program or until the MSP is written. (b) The BRS contractor shall, and require that its BRS provider types listed in section (1)(a) of this rule, ensure that the ISP is individualized, developmentally appropriate, based on a thorough assessment of the BRS client’s referral information, and include at minimum the following: (A) A plan to address specific behaviors and needs identified in the referral information including the intervention to be used; (B) A plan for any overnight home visits and transitional visits; (C) The anticipated discharge date; (D) The anticipated type of placement at discharge; (E) Existing orders for medication and any prescribed treatments for medical conditions, mental health conditions, or substance abuse; (F) Any type of behavior management system that is used as an intervention; and (G) A plan for behavior management needs if needs are greater than usual for the program. (2) Assessment and Evaluation Report (AER): (a) A BRS contractor that provides services and placement-related activities in a Shelter, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Basic Rehabilitation, Intensive Residential, Intensive Rehabilitation or Intensive Behavioral Support program shall, and require that its BRS providers: (A) Ensure that a social service staff member conducts a comprehensive assessment of the BRS client and completes a written AER; and (B) Submit the written AER to the caseworker within 45 days of the BRS client’s admission to its program. (b) The BRS contractor and the BRS provider types listed in section (2)(a) of this rule must ensure that the AER includes information about the BRS client regarding the following domains: (A) Legal custody and basis for custody; (B) Medical information including prescribed medications and dosages; (C) Family or fictive kin information including specific cultural factors; (D) Mental health information; (E) Alcohol and drug use both current and historical; (F) Educational needs; (G) Vocational services, if the BRS client is 14 years of age or older; (H) Social living skills; and (I) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources. (c) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that the AER describes the following: (A) Identified problems, reason for referral or placement, and pertinent historical information; (B) The BRS client’s behaviors, response to current services, and strengths and assets; (C) Significant incidents or interventions or both; (D) A plan for behavior management needs if needs are greater than usual for the program; (E) Identification of any service goals; and (F) Identified needs by assessment and history. (d) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that the Abbreviated AERs meet the following requirements: (A) If a BRS client is transferred to the current BRS program from another BRS program and the client’s most recent AER is less than 90 days old, the current BRS contractor or BRS provider may submit an abbreviated AER to the caseworker within 30 days of the client’s transfer to its program instead of the AER required in section (2) of this rule; (B) The BRS contractor shall, and require that its BRS provider types listed in section (2)(a) of this rule, ensure that an abbreviated AER includes at minimum the information in section (2)(b)(A) of this rule and any other specific information requested by the caseworker. If the information is available, the BRS contractor or BRS provider must also include the information in section (2)(b)(B) through (D) of this rule. (3) Master Service Plan (MSP): (a) A BRS contractor that provides services and placement-related activities in a Shelter, Community Step Down, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support program shall, and require that its BRS provider: (A) Ensure that a social service staff member completes a written individualized MSP within 45 days of the BRS client’s admission to its program; (B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP; (D) Obtain written approval of the MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and (E) Provide the services identified in the MSP. (b) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, ensure that the MSP includes goals that are measurable and attainable within a specified time frame and address at minimum the following domains where need is indicated by the BRS client’s assessment and history: (A) Legal custody and basis for custody; (B) Medical information including medications and dosages; (C) Family or fictive kin information including specific cultural factors; (D) Mental health information; (E) Alcohol and drug use both current and historical; (F) Educational needs; (G) Vocational needs; (H) Social living skills; (I) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources; (J) Other needs identified in the BRS client’s AER that do not fall in one of the other identified domains above; and (K) Completion criteria individualized for each BRS client. Completion is defined by progress in acquiring pro-social behaviors, attitudes, and beliefs while in the program, and not engaging in behavior that seriously jeopardizes the safety of staff and other program participants. (c) The BRS contractor and the BRS provider types listed in section (3)(a) of this rule must ensure that the MSP is individualized and developmentally appropriate and includes: (A) Specifically stated and prioritized service goals for the BRS client that include the caseworker’s recommendations and goals that the BRS client wants to achieve; (B) Specific interventions and services its program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program; (C) Staff responsible for providing the identified services; (D) Specifically stated behavioral criteria for evaluating the achievement of goals; (E) A timeframe for the completion of goals; (F) The method used to monitor the BRS client’s progress towards completing goals; (G) Transition goals and planning; and (H) Aftercare Services, including a detailed description of available services that may be offered to the BRS client. These services can include but are not limited to crisis intervention, service coordination, monitoring, skills training and parent training. (d) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, clearly list in the MSP those needs identified in a BRS client’s AER that are to be addressed by an outside provider and then identify the outside provider that will be responsible for addressing those needs. The BRS contractor shall, and require that its BRS provider, facilitate the BRS client’s access to other providers whenever needs identified in the AER cannot be met within the scope of the services offered by its program; (e) The BRS contractor shall, and require that its BRS provider types listed in section (3)(a) of this rule, also describe in the MSP any plan for the BRS client to participate in overnight home visits or transitional visits, including but not limited to documenting when the home visits or transitional visits are to occur, identifying the frequency of the visits (up to a maximum of eight days per month for a combination of home visits and transitional visits), and describing how the visits relate to the BRS client’s goals identified in the MSP. The BRS contractor shall, and require that its BRS provider, make every attempt to schedule home visits and transitional visits so that they do not conflict with services. Any deviation from the approved home visit and transitional visit plan requires prior written approval from the agency. (4) Master Service Plan 90 Day Updates: (a) A BRS contractor that provides services and placement-related activities in a Shelter, Community Step Down, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support program shall, and require that its BRS provider: (A) Ensure that a social service staff member reviews and updates in writing the BRS client’s MSP no later than 90 days from the date the MSP was first finalized or the last time it was updated and every 90 days thereafter. Social service staff must review the MSP and update it in writing if necessary, earlier whenever additional information becomes available that suggests that other services should be provided; (B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP updates; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP updates; (D) Obtain written approval of an updated MSP prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and (E) Provide the services identified in the most recent MSP update. (b) The BRS contractor shall, and require that its BRS provider types listed in section (4)(a) of this rule, ensure that the written update to the MSP is individualized and developmentally appropriate and includes at minimum the following: (A) The BRS client’s progress towards achieving service goals; (B) The BRS client’s performance on the behavior management system; (C) The BRS client’s performance on any individualized plans developed to address specific behaviors; (D) Any modifications to services based on the BRS client’s new behaviors or identified needs; (E) Any changes regarding recommendations, the discharge date, and transition plans; (F) Aftercare Planning with a detailed description of the services to be delivered to the BRS client and during the aftercare period; and (G) A summary of incidents involving the BRS client that have occurred since the last time the MSP was updated. (5) Aftercare and Transition Plan (ATP): (a) A BRS contractor that provides services and placement-related activities in Community Step Down, Proctor Care, Proctor Enhanced Services, Independent Living, Enhanced Structure Independent Living Program Assessment and Evaluation, Basic Residential, Rehabilitation, Intensive Residential, Intensive Rehabilitation, or Intensive Behavioral Support shall, and require that its BRS provider: (A) Ensure that a social service staff member develops and completes a written ATP at least 30 days prior to, or when there is insufficient notice, as close as possible to 30 days prior to the BRS client’s planned discharge incorporating information from the latest MSP; (B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule and members of the service planning team to participate in developing the BRS client’s written ATP; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule and members of the service planning team were provided with the opportunity to participate in developing the written ATP; (D) Provide a copy of the written ATP to the individuals described in section (1)(a)(B) of this rule and members of the service planning team; and (E) Obtain written approval of the written ATP from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian. (b) The BRS contractor shall, and require that its BRS providers listed in section (5)(a) of this rule, ensure that the written ATP describes how the BRS client will successfully transition from its program to the community, specifically addressing the period of 180 days after discharge from its program. The BRS contractor and BRS provider must ensure that the written ATP includes, at minimum, the following: (A) Identification of the BRS client’s individual needs and unmet goals; (B) Identification of the aftercare services and supports outside of its program that will be available for the 180-day time-period; (C) Identification of the individual or entity responsible for providing the aftercare services outside of its program; and (D) Identification of aftercare services and supports provided by the program to the BRS client that will be available for the 180-day time period. These services may include crisis intervention, service coordination, monitoring, and skills training. Minimum contact schedule is one time per week for the first 30 days, two times per month for the next 60 days, and one time per month for the remaining 90 days. Document the type, duration, and description of contact in the record pertaining to the BRS client. (E) Schedule for regular telephone contact by BRS provider staff with the BRS client and, as applicable, the BRS client’s family, fictive kin, caseworker, or other identified significant individuals. (c) The BRS contractor shall and require that its BRS providers listed in section (5)(a) of this rule, provide services identified in the ATP. (d) The BRS contractor and its BRS provider types listed in section (5)(a) of this rule will not be required to provide aftercare services and supports if the BRS client decline services or when the BRS client transitions to another BRS program. The BRS contractor or BRS provider is still required to complete a written ATP. (e) The BRS contractor or BRS provider types listed in section (5)(a) of this rule may not be required to provide a written ATP under the following circumstances: (A) The agency, legal guardian, or custodian removes the BRS client from the program with little or no notice and in a manner not in accordance with the existing ATP; (B) The BRS client is discharged from the program on an emergency basis due to the BRS client’s behavior, runaway status without a plan to return to the program, or transfer to another program or higher level of care; (C) The BRS client is discharged to another BRS provider; or (D) The BRS client initiates an immediate voluntary discharge from the program. (6) For a discharge summary, a BRS contractor that provides services and placement-related activities in a Shelter, Community Step-down, Independent Living program, Enhanced Structure Independent Living program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation Services, Intensive Residential, Intensive Rehabilitation, Short-Term Stabilization, or Intensive Behavioral Support program shall, and require that its BRS provider, ensure that a social service staff member completes and provides a written discharge summary to the caseworker within 15 days following the BRS client’s planned or actual discharge from its program. The discharge summary must include the BRS client’s progress towards service goals. (7) Aftercare Summary: (a) A BRS contractor that provides services and placement-related activities in a Community Step-down, Independent Living, Enhanced Structure Independent Living Program, Proctor Care, Proctor Enhanced Services, Assessment and Evaluation, Basic Residential, Rehabilitation Services, Intensive Residential, Intensive Rehabilitation, Short-Term Stabilization, and Intensive Behavioral Support program shall, and require that its BRS provider: (A) Ensure that a social service staff member completes and provides a written aftercare summary to the caseworker within 210 days following the BRS client’s discharge from its program; (B) Summarize the BRS client’s status and progress on the ATP for the 180 days following the client’s discharge from the BRS provider, including but not limited to the client’s adjustment to the community and any further recommendations; (C) Summarize the specific services provided by the BRS contractor and BRS provider for the 180 days following discharge to include a description of each type of service provided, number of service hours provided per month, and the names of individuals receiving the services. (b) An aftercare summary is not required if the BRS provider type listed in section (7)(a) of this rule was not required to complete an ATP under circumstances listed in section (5)(e)(A-E) of this rule. (8) Master Service Plan – Transition (MSP-T): (a) A BRS contractor that provides services and placement-related activities in an Independent living program or Enhanced Structure Independent Living program shall, and require that its BRS provider: (A) Ensure that the transition facilitator completes with the BRS client a standardized assessment of independent living skills prior to the development of the MSP-T; (B) Ensure that a transition facilitator in collaboration with the BRS client completes a written MSP-T within 30 days of the BRS client’s admission to the program; (C) Provide the services identified in the MSP-T; (D) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-T; (E) Ensure the MSP-T is individualized and developmentally appropriate and includes: (i) Specifically stated and prioritized service goals for the BRS client that include the caseworker’s recommendations and goals that the BRS client wants to achieve; (ii) Specific interventions and services the program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program; (iii) Staff responsible for providing the identified services; (iv) Specifically stated behavioral criteria for evaluating the achievement of goals; (v) A timeframe for the completion of goals; (vi) The method used to monitor the BRS client’s progress towards completing goals. (b) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-T; (c) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, obtain and maintain written approval of the MSP-T prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the client’s parent, guardian, or legal custodian; (d) The BRS contractor shall, and require that its BRS provider type listed in section (8)(a) of this rule, ensure that the MSP-T includes goals that are measurable and attainable within a specified time frame and address at minimum the following domains where need is indicated by an assessment of the BRS client’s referral information and history: (A) Legal custody and basis for custody; (B) Medical information including medications and dosages; (C) Family or fictive kin information including specific cultural factors; (D) Mental health information; (E) Alcohol and drug use including relapse prevention; (F) Educational needs; (G) Vocational needs; (H) Placement plans including home visits, transitional visits, anticipated discharge date, and placement resources; (I) Social living skills needs, including barriers to building healthy social support, recreation, and community connection or membership (including planning for supportive relationships); (J) Independent living skills needs, which may include barriers regarding the use of technology, finances, and consumer awareness, transportation planning and responsibility, and free-time supervision and structure. (9) Master Service Plan — Transition 30-day Updates: (a) The BRS contractor of an Independent Living or Enhanced Structure Independent Living program shall, and require that its BRS provider: (A) Ensure that the transition facilitator in collaboration with the BRS client reviews and updates in writing the BRS client’s MSP-T no later than 30 days from the date the MSP-T was first finalized or the last time it was updated and every 30 days thereafter; (B) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-T update; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-T updates; (D) Obtain written approval of an MSP-T update prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and (E) Provide the services identified in the most recent MSP-T update. (b) The BRS contractor and its BRS provider type listed in section (9)(a) of this rule, must ensure that the written MSP-T update is individualized and developmentally appropriate and includes at minimum the following: (A) The BRS client’s progress towards achieving service goals; (B) The BRS client’s performance on the behavior management system; (C) The BRS client’s performance on any individualized plans developed to address specific behaviors; (D) Any modifications to services based on the BRS client’s new behaviors or identified needs; (E) Any changes regarding recommendations, the discharge date, or aftercare and transition plans; and (F) A summary of incidents involving the BRS client that have occurred since the last MSP-T update. (10) For an Initial Service Plan – Stabilization (ISP-S), a BRS contractor that provides services and placement-related activities in a Short-term Stabilization program shall, and require that its BRS provider: (a) Ensure that a social service staff completes a written ISP-S within two business days of the BRS client’s admission to the program; (b) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s ISP-S; (c) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the ISP-S; (d) Obtain written approval of the ISP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; (e) Provide the services identified in the ISP-S during the BRS client’s first 30 days in the program. (f) Ensure that the ISP-S is individualized, developmentally appropriate, and based on a thorough assessment of the BRS client’s referral information, and includes at minimum the following: (A) A plan to address specific behaviors and needs identified in the referral information including the intervention to be used; (B) A plan for any overnight home visits and transitional visits; (C) The anticipated discharge date; (D) The anticipated type of placement at discharge; (E) Existing orders for medication and any prescribed treatments for medical conditions, mental health conditions, or substance abuse; (F) Any type of behavior management system used as an intervention; (G) A plan for behavior management needs if needs are greater than usual for the program; (H) Objectives for placement as described by the caseworker; and (I) Goals that are measurable and attainable within the first 30 days of the BRS client’s placement in the BRS program. (11) Assessment and Evaluation Report — Stabilization (AER-S): (a) A BRS contractor that provides services and placement-related activities in a short-term stabilization program shall, and require that its BRS provider, ensure a social service staff member conducts an assessment of each BRS client who is expected to remain in the program for more than 30 days; (b) A BRS contractor and BRS provider in a short-term stabilization program shall, after conducting the assessment, require that the staff member submit a written AER-S to the BRS client’s caseworker within 30 days from the date the client was admitted into the program. The written AER-S shall include the following information about the BRS client: (A) A summary of the client’s problems and needs, the reason for referral or placement, and any pertinent historical information; (B) Identified reasons for behavioral instability; (C) Summary of BRS client’s readiness for return to previous placement or recommended placement; (D) The BRS client’s behaviors, response to current services, and strengths and assets; (E) Assessment of BRS client’s characteristics that may require service delivery modifications to ensure successful participation in BRS services; (F) Significant incidents or interventions or both; (G) A plan for behavior management needs if needs are greater than usual for the program, if applicable. (c) The BRS program as described in section (11)(a) of this rule is not required to conduct an assessment or submit a written AER-S, as described in section (11)(b) of this rule, when the BRS client is expected to remain in the program for 30 days or less. (12) Master Service Plan – Stabilization (MSP-S): (a) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider: (A) Ensure that a social service staff completes a written MSP-S within 30 days of the BRS client’s admission to the program; (B) Provide an opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-S; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP-S; (D) Obtain written approval of the MSP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; (E) Ensure that the MSP-S is individualized and based on the BRS client’s needs identified in the AER-S; (F) Provide the services identified in the current MSP-S. (b) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, ensure that the MSP-S describes the following: (A) Specifically stated and prioritized service goals for the BRS client based on the AER-S that include the caseworker’s recommendations and goals that the BRS client wants to achieve; (B) Medical information including medications and dosages. (c) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, ensure that the MSP-S is individualized and developmentally appropriate and includes: (A) Specific interventions and services its program shall provide to address each goal, including the use of a behavior management system as an intervention and a plan for behavior management needs if needs are greater than usual for the program; (B) Staff responsible for providing the identified services; (C) Specifically stated behavioral criteria for evaluating the achievement of goals; (D) A timeframe for the completion of goals; (E) The method used to monitor the BRS client’s progress towards completing goals; (F) Aftercare and transition goals and planning, including anticipated discharge date and placement resource; (G) Completion criteria individualized for each BRS client. Completion is defined by progress in acquiring pro-social behaviors, attitudes, and beliefs while in the program and not engaging in behavior that seriously jeopardizes the safety of staff and other program participants. (d) For the Assessment and Evaluation Report, the BRS contractor of a short-term stabilization program shall, and require its BRS provider, to identify in the MSP-S those needs identified in a BRS client’s AER-S that will be addressed by an outside provider and identify that provider. The BRS contractor shall, and require that its BRS provider, facilitate the BRS client’s access to other providers whenever needs identified in the AER-S cannot be met within the scope of the services offered by its program; (e) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider, describe in the MSP-S any plan for the BRS client to participate in overnight home visits and transitional visits, including but not limited to documenting when the home visits and transitional visits are to occur, identifying the frequency of the visits (up to a maximum of eight days per month), and describing how the visits relate to the BRS client’s goals identified in the MSP-S. The BRS contractor shall, and require that its BRS provider, make every attempt to schedule home and transitional visits so that they do not conflict with services. Any deviation from the approved home visit and transitional visit plan requires prior written approval from the BRS client’s caseworker. (13) Master Service Plan – Stabilization Updates (MSP-S): (a) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider: (A) Ensure that a social service staff member reviews and updates in writing the BRS client’s MSP-S no later than 30 days from the date the MSP-S was first finalized or the last time it was updated and every 30 days thereafter. Social service staff must review the MSP-S and update it in writing earlier, if necessary, whenever additional information becomes available that suggests that other services should be provided; (B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule to participate in developing the BRS client’s MSP-S updates; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule were provided with the opportunity to participate in developing the MSP updates; (D) Obtain written approval of an updated MSP-S prior to its implementation from the caseworker and, as applicable and appropriate, the BRS client and the BRS client’s parent, guardian, or legal custodian; and (E) Provide the services identified in the most recent MSP-S update. (b) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider, ensure that the written update to the MSP-S is individualized and developmentally appropriate and includes at minimum the following: (A) The BRS client’s progress towards achieving service goals; (B) The BRS client’s performance on the behavior management system; (C) Any modifications to services based on the BRS client’s new behaviors or identified needs; (D) Any changes regarding recommendations, the discharge date, or aftercare and transition plans; and (E) A summary of incidents involving the BRS client that have occurred since the last time the MSP-S was updated. (14) Aftercare and Transition Plan - Stabilization (ATP-S): (a) The BRS contractor of a Short-term Stabilization program shall, and require that its BRS provider: (A) Ensure that a social service staff member develops and completes a written ATP-S at least 30 days prior to or as close as possible to the BRS client’s planned discharge; (B) Provide the opportunity for the individuals listed in section (1)(a)(B) of this rule and members of the service planning team to participate in developing the BRS client’s written ATP-S; (C) Obtain and maintain documentation that the individuals listed in section (1)(a)(B) of this rule and members of the service planning team were provided with the opportunity to participate in developing the written ATP-S; (D) Provide a copy of the written ATP-S to the individuals described in section (1)(a)(B) of this rule and members of the service planning team; and (E) Obtain written approval of the written ATP-S from the caseworker and, as applicable and appropriate, the BRS client and the client’s parent, guardian, or legal custodian. (b) The BRS contractor of a short-term stabilization program shall, and require its BRS provider, ensure the written ATP-S describes how the BRS client is successfully transitioning from its program to the community, specifically addressing the period of 180 days after discharge from its program. The BRS contractor shall, and require that its BRS provider, ensure the written ATP-S includes, at minimum, the following: (A) Identification of the BRS client’s individual needs and unmet goals; (B) Identification of the aftercare services and supports outside of its program that are available for the 180-day time-period; (C) Identification of the individual or entity responsible for providing the aftercare services. (D) Identification of aftercare services and supports provided by the BRS program to the BRS client that will be available for the 180-day time period. These services may include crisis intervention, service coordination, monitoring, and skills training. Minimum contact schedule is one time per week for the first 30 days, two times per month for the next 60 days, and one time per month for the remaining 90 days. Document the type, duration, and description of contact in the record pertaining to the BRS client. (E) Schedule for regular telephone contact by BRS provider staff with the BRS client and, as applicable, the BRS client’s family, fictive kin, caseworker, or other identified significant individuals. (c) The BRS contractor of a short-term stabilization program shall, and require that its BRS provider, complete an ATP-S for BRS clients who are being discharged home or into a non-BRS foster care placement; (d) The BRS contractor or BRS provider will not be required to provide aftercare services and supports if the BRS client decline services as documented in the ATP-S. The BRS contractor or BRS provider is still required to complete an ATP-S. (e) The BRS contractor or BRS provider of a short-term stabilization program may not be required to provide a written ATP-S under the following circumstances: (A) The agency, legal guardian, or custodian removes the BRS client from the program with little or no notice and in a manner not in accordance with the current service plan; (B) The BRS client is discharged from the program on an emergency basis due to the BRS client’s behavior, runaway status without a plan to return to the program, or transfer to another program or higher level of care; or (C) The BRS client initiates an immediate voluntary discharge from the program. (15) The BRS contractor shall, and require that its BRS provider, ensure that all BRS service plans described in this rule are developed and maintained in the BRS client’s case file in accordance with the timeframes and criteria in this rule, unless otherwise exempted.