(1) This section only applies to an RTF in its licensed capacity to provide pediatric transitional care services according to this chapter.

(2) The licensee must develop, implement, and update at least weekly an individual service plan for each infant receiving pediatric transitional care services based on the infant's:

(a) Initial health on admission; and

(b) Health assessment(s) described in WAC 246-337-081.

(3) Each individual service plan must:

(a) Establish a plan of management for neonatal abstinence syndrome prepared by a health care provider who is:

(i) Involved with the infant's care; and

(ii) Working within their scope of practice.

(b) Be prepared in accordance with the infant's standing orders;

(c) Include short-term goals;

(d) Establish timelines for initial and ongoing visitation between the infant and parents, guardians, or identified family resources according to WAC 246-337-082;

(e) Include a discharge plan that addresses, at minimum, the following:

(i) Medical release from a pediatrician, physician's assistant, or pediatric ARNP indicating that the infant is medically stable and appropriate for discharge;

(ii) Verification of a receiving physician, pediatrician, physician's assistant, or ARNP who will assume infant care and receive relevant health care records;

(iii) Verification from a registered nurse that the infant has achieved weight and feeding milestones appropriate for discharge;

(iv) Written after care plan for the infant, developed in collaboration with the parents, which includes specific tasks for parents. Parents must sign the after care plan prior to infant discharge; and

(v) Assessment that the home environment and family dynamics are appropriate to receive and care for the infant.

(f) Include an aftercare plan that addresses, at minimum, the following:

(i) A plan to regularly communicate with the parents or guardian for a minimum of six months after discharge to check on the infant's condition and offer consultation and community resource referrals as needed; and

(ii) Provide the infant's family appropriate staff contacts in case family needs consultation.