Sec. 10.21.20.06. Evaluative Services Provided

A. Assessment and Diagnosis. The medical director shall ensure that an appropriate licensed mental health professional shall, by the individual's second visit and based on the initial face-to-face diagnostic evaluation of the individual:

(1) Formulate and document in the individual's medical record information that includes:

(a) A description of the presenting problem;

(b) Relevant history, including family history and somatic problems;

(c) Mental status examination; and

(d) A diagnosis and the rationale for the diagnosis; or

(2) Document:

(a) The reason for not formulating a diagnosis; and

(b) A plan, including time frame, for formulating a diagnosis.

B. Co-Occurring Substance Abuse Screening Assessment. The face-to-face diagnostic assessment conducted under §A of this regulation shall include a screening assessment, using a scientifically validated, and if available, age appropriate tool, to determine whether the individual has a co-occurring substance abuse disorder.

C. Additional Assessment for a Minor. In addition to the requirements outlined in §A of this regulation, before a minor's fifth visit, the minor's assigned treatment coordinator shall:

(1) Conduct a face-to-face evaluation with the minor to assess the minor's level of functioning and availability of family and other social supports; and

(2) If a comprehensive assessment, that includes the elements listed in §C(2) of this regulation, has not been completed within the 6 months before enrollment, assure the completion of an assessment, that includes, at a minimum, the minor's:

(a) Developmental history;

(b) Educational history and current placement;

(c) Home environment;

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

(e) Social, emotional, and cognitive development;

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

(g) History, if any, of substance abuse;

(h) History, if any, of physical or sexual abuse;

(i) History, if any, of out-of-home placements; and

(j) Involvement, if any, with the local department of social services or Department of Juvenile Services.

D. Review of Somatic Status.

(1) According to the provisions described in §D of this regulation and upon an individual's enrollment into the program, an appropriate licensed mental health professional shall document in the individual's medical record:

(a) Pertinent past and current somatic medical history including:

(i) The individual's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases;

(ii) Relevant medical treatment, including medication; and

(iii) A recommendation, if any, for somatic care follow-up;

(b) If the individual does not have a primary care provider, the plan, if indicated, including the time frame, for the individual's referral to a primary care provider for evaluation and treatment; and

(c) An exchange of medical information with the primary care provider.

(2) With proper consent and if clinically indicated, the individual's treatment coordinator shall maintain and document ongoing collaboration and coordination with the individual's primary care provider.