Sec. 10.21.18.05. Evaluative Services for the Child

A. Assessment. If a comprehensive developmental assessment has not been completed within the 90 days before admission, before the child's 6th visit, the therapeutic nursery staff shall assure the completion of an assessment, including, when appropriate, standardized measurement, that includes, at a minimum, an assessment of the following:

(1) Social and emotional development;

(2) Cognitive skills and deficits;

(3) Language development;

(4) Motor skills, fine and gross;

(5) Self-help and adaptive skills;

(6) Family history and evaluation;

(7) Home environment;

(8) Developmental history;

(9) Mental status; and

(10) Medical history and needs, if any.

B. Diagnosis. Before the child's 6th visit, an individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, shall:

(1) Conduct a face-to-face evaluation of the child;

(2) Formulate and document a diagnosis; and

(3) Document the rationale for the diagnosis.

C. Individual Treatment Plan (ITP).

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

(a) At least one of the following:

(i) The therapeutic nursery physician; or

(ii) A staff psychologist or psychologist consultant;

(b) At least one other mental health professional;

(c) All therapeutic nursery staff who are involved in providing services to the child and family; and

(d) If the therapeutic nursery is affiliated with an educational preschool program, the educational staff, as determined appropriate by the therapeutic nursery clinical director.

(2) Plan. Before the child's 6th visit, the therapeutic nursery treatment team, working cooperatively with the child's primary caretaker and classroom teacher, shall prepare an ITP that includes:

(a) The diagnostic formulation, as required by §B of this regulation;

(b) A description of the child's behavior that includes:

(i) Problem list; and

(ii) Asset list;

(c) Goals and objectives stated in behavioral, measurable terms;

(d) Treatment strategies;

(e) Classroom interventions;

(f) Home interventions;

(g) For children in Program A, that portion of an IFSP, if any, that pertains to therapeutic nursery services; and

(h) As relevant, the information about the following from the child's parent, guardian, or primary caretaker, in consultation with appropriate health care or other service providers:

(i) Instructions for care in an emergency;

(ii) History of allergies, including to medication;

(iii) History of seizures;

(iv) Medication prescribed;

(v) Nutritional requirements, limitations, and feeding procedures; and

(vi) Essential medical or nonmedical treatments or procedures, including any advanced directives.

(3) Signatures on the ITP. The following shall sign the ITP:

(a) The treatment coordinator of the therapeutic nursery;

(b) The therapeutic nursery physician, staff psychologist, or psychologist consultant;

(c) If the child is receiving medication, the therapeutic nursery physician;

(d) If the individual who signs under the provisions of §C(3)(b) of this regulation is also the treatment coordinator, at least one other mental health professional; and

(e) Following review of the ITP, the parent, guardian, or primary caretaker.

(4) 45-Day Review. At a minimum of every 45 days:

(a) The treatment coordinator shall:

(i) Review the progress on the ITP;

(ii) Document in the child's record a description of progress toward goals and changes in goals and interventions based on the review of progress under §C(4)(a)(i) of this regulation; and

(iii) Update the ITP accordingly; and

(b) A minimum of two treating mental health professionals shall sign the 45-day review.

(5) 3-Month Review. Every 3 months, at a treatment team meeting, the:

(a) Treatment team shall review the ITP according to the process outlined in §C(4) of this regulation;

(b) Treatment coordinator shall update and sign the 3-month review; and

(c) Therapeutic nursery physician, staff psychologist, or psychologist consultant shall sign the ITP review.

D. Continuing Evaluation. In order to ensure that services to a child are timely and appropriate, therapeutic nursery staff shall document in the child's record:

(1) As outlined in the policy and procedures manual, contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the child, including the dates, locations, and types of contacts; and

(2) Progress summary notes, entered at least monthly, by staff members involved in the child's treatment and classroom activities, regarding progress toward treatment goals.