Sec. 10.21.19.05. Evaluative Services Provided

A. Initial MTS Psychiatric Evaluation. Within 30 days of receipt of referral for MTS, the MTS psychiatrist, in collaboration with the individual's assigned treatment coordinator, shall conduct a face-to-face evaluation of the individual to:

(1) Collect and evaluate relevant history;

(2) Evaluate current mental status, including:

(a) The need for medication; and

(b) A review of current medications and source of prescriptions;

(3) Assess the individual's general physical health, and either:

(a) Perform a physical examination;

(b) Document a physical examination of the individual during the prior year;

(c) Refer the individual for a physical examination; or

(d) Waive the requirement that the individual have a physical examination and document the rationale for the waiver;

(4) Formulate and document the psychiatric diagnosis and the rationale for the diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record;

(5) In collaboration with the individual:

(a) Identify the individual's needs, strengths, and goals; and

(b) Assess the individual's level of functioning and availability of family and other social supports;

(6) Document the rationale for the determination that MTS are medically necessary; and

(7) Develop an initial brief plan of care.

B. Diagnosis.

(1) As required under §A(4) of this regulation, the MTS psychiatrist shall conduct the evaluation and formulate and document the psychiatric diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record.

(2) An individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, may provide continuing psychiatric diagnosis.

C. Individual Treatment Plan (ITP).

(1) Treatment Team. At least the following shall participate as members of an individual's MTS treatment team:

(a) The MTS psychiatrist or a third-year or fourth-year psychiatric resident who is supervised by the MTS psychiatrist;

(b) A licensed social worker;

(c) A registered nurse;

(d) The individual's treatment coordinator, as defined under Regulation .09 of this chapter; and

(e) When available, any other staff involved in providing services to the individual.

(2) Initial ITP. Before the 45th day after an individual is admitted to MTS, based on the screening assessment under Regulation .04B of this chapter and psychiatric evaluation under Regulation .05A of this chapter, the treatment team, under the direction of the treatment coordinator, in collaboration with the individual and, with proper consent, family members or significant others designated by the individual, shall prepare an ITP that includes:

(a) The psychiatric diagnosis;

(b) Description of the individual's current behavior and level of functioning that includes the individual's needs and strengths;

(c) When relevant to the individual, a description of the family's or significant others' needs and strengths;

(d) Short-term and long-term goals, including the plan for transitioning to traditional outpatient mental health services, that are outcome-oriented and that are stated in behavioral, measurable terms;

(e) Treatment strategies, including:

(i) Recommended type and frequency of interventions;

(ii) The method of providing the services required under Regulation .06 of this chapter; and

(iii) Target dates for goal achievement; and

(f) The designation of MTS staff responsible for implementing the elements of the plan.

(3) 3-Month ITP Review. At a minimum of every 3 months at a treatment team meeting, the individual's treatment coordinator, in collaboration with the individual, shall review the ITP and record in the individual's medical record:

(a) A description of progress toward the goals;

(b) Changes in goals and interventions based on the review of progress documented by the individual's treatment coordinator; and

(c) A statement validating the need for continued MTS.

(4) Signature of the ITP and ITP Reviews.

(a) The individual shall sign or tape record agreement or disagreement with the plan.

(b) The MTS psychiatrist and the individual's treatment coordinator shall sign the ITP and the ITP 3-month reviews.

D. Continuing Evaluation. In order to ensure that services to an individual are timely and appropriate, the staff shall document in the individual's medical record:

(1) Contact notes, regarding all face-to-face and other clinically relevant contacts with or about the individual; and

(2) Progress summary notes, entered at least monthly by the individual's treatment coordinator, that include:

(a) A description of progress toward the goals; and

(b) Changes in goals and interventions based on the review of progress.