(1) If the assessing treatment professional recommends psychoactive medications, the prescribing professional or service provider must document this in the client's psychoactive medication treatment plan. The service provider must ensure the plan includes the following:

(a) A description of the behaviors, symptoms or conditions for which the medication is prescribed and a mental health diagnosis, if available;

(b) The name, dosage, and frequency of the medication and subsequent changes in dosage must be documented in the person's medical record;

(c) The length of time considered sufficient to determine if the medication is effective;

(d) The behavioral criteria to determine whether the medication is effective and what changes in behavior, mood, thought, or functioning are considered evidence that the medication is effective; and

(e) The anticipated schedule of visits with the prescribing professional.

(2) The service provider must make sure the treatment plan is updated when there is a change in psychoactive medication type, including intraclass changes.

(3) The service provider must:

(a) Review the name, purpose, potential side effects and any known potential drug interactions of the psychoactive medication(s) with the client and his/her legal representative and document the review in the client record; and

(b) Have available to staff and clients an information sheet for each psychoactive medication that is being used by each client served by the provider.

(4) The service provider must assist the client in obtaining and taking the medication when:

(a) The client's legal representative if any, is unavailable; and

(b) In the prescribing professional's opinion, medication is needed and no significant risks are associated with the use of the medication.

(5) If a client takes psychoactive medications to reduce challenging behaviors or to treat symptoms of a mental illness that are interfering with the client's ability to have positive life experiences and form and maintain relationships, the service provider must develop and implement a positive behavior support plan.