Sec. 10.21.20.08. Treatment Services

A. An OMHC shall have the capacity to provide the treatment services outlined in §§B-F of this regulation as required by the individual's ITP.

B. Mental Health Treatment. The program director shall ensure that licensed mental health professionals provide mental health treatment including:

(1) Individual therapy;

(2) Family therapy; and

(3) Group therapy.

C. Psychological Evaluation and Testing. The program director shall ensure that, if medically necessary and required by an individual's ITP, the OMHC provides psychological evaluation and testing by a staff psychologist or psychologist consultant, or by referral.

D. Co-Occurring Substance Abuse Treatment.

(1) The program director shall ensure that the program provides substance abuse treatment as a component of its mental health program for individuals with secondary co-occurring disorders or has a written plan to coordinate mental health services with a certified substance abuse program if necessary.

(2) If the assessment conducted under Regulation .06B of this chapter indicates that the individual has a secondary co-occurring substance abuse disorder, the individual's treatment plan and progress notes shall:

(a) If the program is providing substance abuse treatment, reflect the course of treatment relative to the disorder; or

(b) If the program is not providing substance abuse treatment, with proper consent and if indicated, include documentation of coordination of care and collaboration with the provider of substance abuse services.

E. Medication Services.

(1) The medical director shall ensure that appropriate staff are trained and updated on the use, effect, interactions, and potential side effects of medication used by individuals served by the program.

(2) Appropriate licensed mental health professionals shall, as clinically indicated, provide the following services:

(a) Prescription;

(b) Administration;

(c) Monitoring; and

(d) Education regarding medication.

(3) Prescription. Staff identified under §E(2) of this regulation shall:

(a) When initially prescribing medication for an individual:

(i) Conduct a face-to-face evaluation of the individual;

(ii) Assess whether there are contraindications to prescription of specific medications;

(iii) Involve the individual in the choice of medication;

(iv) Document in the individual's medical record the rationale for prescribing the medication;

(v) Explain the benefits and possible side effects of taking or not taking prescribed psychiatric medications and document the explanation;

(vi) With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of the medication regimen; and

(vii) With proper consent and if clinically indicated, notify the individual's primary care physician of medication prescription, if any; and

(b) If managing medication on an ongoing basis:

(i) At a minimum of every 90 days, evaluate the individual face-to-face;

(ii) Alter medications and adjust dosage as clinically indicated;

(iii) Document the rationale for the current prescription;

(iv) Order and monitor tests at medically recommended intervals and document results in the individual's medical record;

(v) Educate the individual and others designated by the individual about prescribed medications, including the name of medication, dosage, frequency, proper storage, expected results, and potential side effects;

(vi) With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of any changes in the medication regimen; and

(vii) Notify the individual's primary care physician every 6 months of medication changes, if any.

F. On-Call and Crisis Intervention Services.

(1) The program director shall ensure that on-call and crisis intervention services are provided by a program's licensed mental health professional to an individual who has been enrolled in the OMHC:

(a) Face-to-face during the 40 hours that the OMHC is open; or

(b) By telephone, on an on-call basis, 24 hours per day, 7 days per week, during the hours the OMHC is not open:

(i) Through the OMHC; or

(ii) By written agreement with another OMHC or mental health crisis service provider.

(2) If clinically appropriate, a crisis response plan or an advance directive for mental health services shall be developed and documented in the medical record, that:

(a) An individual and, if the individual is a minor, the primary caretaker may implement in the event of or to prevent a crisis at home, school, work, or other setting in which the individual is involved; and

(b) Is stated in terms that the individual and, if involved, the primary caretaker understand.