Sec. 10.21.07.11. Evaluative Services Provided by the TGH

A. Therapeutic Milieu. The clinical coordinator, as defined in Regulation .14C of this chapter, shall assure maintenance of the therapeutic milieu in order to foster achievement of a child's treatment goals.

B. Diagnosis. Within 1 week of a child's admission to the TGH, the clinical coordinator shall ensure that a staff member authorized under the Health Occupations Article, Annotated Code of Maryland, and credentialed and privileged by the program to formulate a psychiatric diagnosis, shall:

(1) Formulate and document in the child's medical record a diagnosis based on a face-to-face assessment of the child, that includes:

(a) A description of the presenting problem;

(b) Relevant history;

(c) Mental status examination; and

(d) The rationale for the diagnosis; or

(2) Affirm the psychiatric diagnosis documented as part of the application for admission under Regulation .09B(3) of this chapter that has been entered in the child's medical record.

C. Assessment. Using the evaluation materials submitted as part of the application for admission, before or within 1 week of the child's admission to the TGH, the TGH clinical coordinator shall assure the completion of an assessment that includes, as indicated, an assessment of the child's:

(1) Developmental history;

(2) Educational history;

(3) Family history and evaluation of current family status, including legal custody status;

(4) Home environment;

(5) Social, emotional, and cognitive development;

(6) Motor, language, and self-care skills development;

(7) History, if any, of:

(a) Substance abuse;

(b) Physical or sexual abuse; and

(c) Home or community violence;

(8) Local department of social services or Department of Juvenile Services involvement, if any;

(9) Mental status; and

(10) Medical history and needs, including, if any, history of allergies, neurologic disorders, and communicable diseases.

D. Initial Brief Treatment Plan. Not later than 1 week following admission, the TGH clinical coordinator shall prepare an initial brief treatment plan:

(1) Based on the:

(a) Application materials submitted as required under Regulation .09B of this chapter; and

(b) Assessment under §C of this regulation;

(2) In collaboration with:

(a) The child;

(b) The primary caretaker;

(c) Appropriate TGH staff; and

(d) As appropriate and with proper consent, interested and available community treatment providers; and

(3) That includes, at a minimum:

(a) The treatment goals expressed by the referring agency, if any;

(b) The process of orientation to the TGH; and

(c) Initial expectations regarding the child's adjustment to residential placement.

E. TGH Individual Treatment Plan (ITP).

(1) Treatment Team.

(a) At a minimum, the following individuals shall participate on a child's treatment team:

(i) The TGH psychiatrist;

(ii) The clinical coordinator;

(iii) The child's case coordinator; and

(iv) Other TGH staff who are involved in providing services to the child and family.

(b) The clinical coordinator shall invite, as appropriate and with proper consent, family members and community-based providers of services to the child, including but not limited to school and mental health treatment staff, to participate as members of the child's treatment team.

(2) Initial ITP. Within 30 days after a child is admitted to a TGH and based on the initial brief treatment plan and current observations and reports, the TGH clinical coordinator shall prepare an ITP to be addressed by TGH staff:

(a) In collaboration with:

(i) The child;

(ii) The treatment team;

(iii) If present and as appropriate, the primary caretaker, family and others involved in the child's care; and

(iv) Other providers of care or treatment;

(b) That identifies the:

(i) Providers of mental health treatment;

(ii) Providers of medical and dental care;

(iii) Educational program; and

(iv) TGH case coordinator;

(c) That is coordinated with the child's:

(i) Individualized educational plan (IEP), when applicable;

(ii) ITP prepared by the providers of mental health treatment; and

(iii) Medical care provider;

(d) That documents the following information:

(i) Based on the physical examination required under Regulation .10A of this chapter, somatic care recommendations, including any medication prescribed, and precautions;

(ii) Nutritional requirements and limitations, if any; and

(iii) Essential medical or non-medical treatments or procedures, if any;

(e) That includes, at a minimum:

(i) The psychiatric diagnosis, as documented under §B of this regulation, in consultation with the providers of mental health treatment;

(ii) A description of the child's current behavior, symptoms, and level of functioning that includes the child's presenting strengths, needs, and treatment expectations and responsibilities;

(iii) A description of the family's or significant others' strengths and needs, as they relate to the child;

(iv) When appropriate, identification of particular behaviors that result or may be expected to result from the child's psychiatric symptoms;

(v) Based on consultation with the providers of education and mental health treatment, short-term and long-term mental health treatment goals that are outcome-oriented and that are stated in behavioral, measurable terms;

(vi) As needed, other goals related to family, socialization and recreation, and activities of daily living; and

(vii) Identification of any medication prescribed for the treatment of a mental disorder and required monitoring of same; and

(f) That specifies treatment strategies to be provided by TGH staff, including:

(i) Recommended modality and frequency of interventions;

(ii) Target dates for goal achievement;

(iii) The designation of TGH staff responsible for implementing the elements of the plan; and

(iv) When appropriate, identification of, referral to, and collaboration with other services to support the child's treatment.

(3) ITP Review. As frequently as necessary, as determined by the TGH clinical coordinator, and, at a minimum of every 90 days, at a treatment team meeting with, unless clinically contraindicated, the child, the clinical coordinator shall:

(a) Review and record in the child's medical record:

(i) The child's progress toward the accomplishment of previously identified mental health treatment and other goals;

(ii) Goal changes based on a review of progress;

(iii) Changes in treatment strategies; and

(iv) Changes in diagnosis; and

(b) Communicate the results of the treatment plan review to:

(i) The child, if the child did not attend the ITP review team meeting;

(ii) The primary caretaker, if present;

(iii) Relevant program staff; and

(iv) The providers of mental health treatment services.

(4) Signature of the ITP and ITP Reviews.

(a) The child and the child's parent or guardian shall sign or tape-record agreement or disagreement with the ITP and reviews.

(b) A child's primary caretaker, if other than the parent or guardian, shall sign or tape-record acknowledgment of the ITP and reviews.

(c) In addition, the following TGH staff shall sign the ITP and reviews:

(i) Psychiatrist;

(ii) Clinical coordinator; and

(iii) Case coordinator.

(d) If the child’s parent, guardian, or primary caretaker does not sign the ITP or ITP reviews, staff shall document efforts to obtain the signature and reason why the signature could not be obtained.

F. Continuing Evaluation.

(1) Contact Notes. Staff involved in the contact shall document in the child's TGH medical record all significant clinically relevant face-to-face, telephone, and written contacts with or about the child, including the dates, locations, and types of contacts.

(2) Progress Summary Notes. At least every 2 weeks, a child's case coordinator shall:

(a) Record in the child's TGH medical record a progress summary note regarding:

(i) The delivery of services specified by the ITP;

(ii) Progress toward goal achievement;

(iii) Changes in the individual's status; and

(iv) If applicable, suggested changes in treatment goals and services delivered; and

(b) Assure that the child's needs and progress are communicated to those listed under §E of this regulation.