Sec. 10.21.26.06. Evaluative Services

A. Initial Evaluation. Before the development of the individual treatment plan (ITP), an individual entitled under Health Occupations Article, Annotated Code of Maryland, to render a psychiatric diagnosis shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to:

(1) Describe the presenting problem and history of present illness;

(2) Collect and evaluate relevant medical and mental health history, including, if any:

(a) Previous inpatient and outpatient treatment; and

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

(3) Evaluate current mental status;

(4) Either:

(a) Formulate and document a psychiatric diagnosis and the rationale for the diagnosis; or

(b) Affirm the psychiatric diagnosis, not more than 1 year old, formulated by the referral source and documented in the individual's medical record; and

(5) Identify needed treatment.

B. Assessment. Before the development of the ITP, the individual's assigned treatment coordinator shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to:

(1) Identify the individual's strengths, needs, and desires;

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

(3) Complete an assessment that includes, at a minimum, a review of:

(a) The individual's:

(i) Legal status;

(ii) Housing status;

(iii) Current employment and economic status;

(iv) History of substance abuse;

(v) History of physical or sexual abuse;

(vi) History of violence or assaultive behaviors;

(vii) Natural support system;

(viii) Activities of daily living; and

(ix) Interpersonal skills; and

(b) For a child, in addition to the requirements of §B(3)(a) of this regulation, the child's:

(i) Developmental status;

(ii) Educational history and current placement;

(iii) Involvement with other agencies;

(iv) Home environment; and

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

(4) Initiate the process to determine who will provide the individual's mental health care and treatment upon discharge from crisis services.

C. Diagnosis. The program director shall assure that, before the development of the ITP, RCS staff documents the psychiatric diagnosis rendered according to §A(4) of this regulation.

D. Somatic Care.

(1) The program director shall assure that RCS staff coordinates an individual's care with, when known and with proper consent, the individual's somatic care provider.

(2) Within 48 hours before or not more than 72 hours after an individual's admission into the program, an individual authorized under Health Occupations Article, Annotated Code of Maryland, shall:

(a) Assess the individual's general physical health;

(b) Determine whether the individual requires a physical examination or somatic care follow-up; and

(c) Make appropriate referrals for services.