Sec. 10.21.17.04. Consent for Services, Orientation, and Advance Directive for Mental Health Services

A. Consent for Services.

(1) Before initiating services to an individual, a program shall:

(a) Obtain consent from the individual to:

(i) Render services to the individual; and

(ii) Involve, as appropriate, the appropriate CSA, the individual's family members, and others designated by the individual in the individual's service process;

(b) Review with the individual:

(i) That the program may disclose, without consent, certain protected health information, and obtain an acknowledgment from the individual of having received notice that such disclosure may occur;

(ii) That the program may disclose, without consent, protected health information to other medical assistance programs and providers; and

(iii) The requirements of the Health Insurance Portability and Accountability Act and the Maryland Medical Records Act, as to scope and limits of the confidentiality provisions; and

(c) If the individual is a minor who cannot consent to services, obtain the appropriate consents and make the required disclosures.

(2) If the individual agrees to consent to services but is unable or unwilling to give written consent, a program shall:

(a) Document the reasons why the individual cannot give written consent;

(b) Verify the individual's verbal consent to services; and

(c) Periodically attempt to obtain written consent and document such efforts.

B. Orientation.

(1) On or before the date that an individual receives services, the program director shall ensure that an individual who has been admitted to the program receives information, verbally and in writing, including, but not limited to:

(a) A description of the services available;

(b) Individual rights and responsibilities;

(c) Program hours and on-call procedures;

(d) The program's procedures for discharge;

(e) The program's procedures for confidentiality;

(f) Crisis intervention services; and

(g) The complaint and grievance processes.

(2) The individual's program coordinator shall document in the individual's medical record the individual's receipt of the information contained in §B(1) of this regulation.

C. Advance Directive for Mental Health Services. For individuals who are 16 years old or older, the program director shall:

(1) Ensure that an individual who has been admitted to the program receives information, verbally and in writing, regarding making an advance directive for mental health services;

(2) Document whether an individual has a current advance directive for mental health services;

(3) If an individual has a mental health advance directive, include a copy of the document in the individual's medical record; and

(4) If an individual requests assistance with making an advance directive for mental health services, assign staff to assist the individual.