Md. Code Regs. 10.21.29.06

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.21.29.06 - Evaluation and Planning Services

A. Review of Somatic Status.

(1) According to provisions outlined in this section and upon a minor's enrollment into the program, a staff member assigned by the program director shall document in the minor's medical record:

(a) Pertinent past and current medical history including:

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

(ii) Relevant medical treatment, including medications; and

(iii) Needed somatic care follow-up, if any; and

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

(2) If indicated, the minor's rehabilitation coordinator shall document and communicate with the minor's primary care provider.

(3) If indicated, the minor's rehabilitation coordinator shall discuss with the minor, and the parent or guardian, if appropriate, the need for medical care and facilitate access to said care.

B. Rehabilitation Assessment.

(1) Within 14 calendar days of initiation of PRP services, PRP staff assigned by the program director to conduct assessments, in collaboration with the minor and, with proper consent, the parent or guardian, shall complete a face-to-face rehabilitation assessment.

(2) The assigned staff shall document in the rehabilitation assessment, at a minimum:

(a) The minor's age and developmentally appropriate strengths, skills, and needs in the following areas:

(i) Self-care skills;

(ii) Social, peer, family, and teacher interaction skills;

(iii) Participation in psychiatric treatment;

(iv) Semi-independent living skills;

(v) Family support and resources;

(vi) Academic achievement;

(vii) Community and informal support systems; and

(viii) Adaptive equipment or resources;

(b) As relevant, a review of the minor's legal status and forensic history, if any; and

(c) The minor's history of physical abuse, sexual abuse, or substance abuse, if any.

C. Individual Rehabilitation Plan.

(1) Initial IRP. Within 30 calendar days of initiation of PRP services and based on the rehabilitation assessment described in §B of this regulation, the minor's rehabilitation coordinator shall prepare an initial IRP:

(a) In collaboration with:

(i) The minor;

(ii) The parent or guardian, if appropriate; and

(iii) If appropriate and with proper consent, other mental health service providers, as available;

(b) That includes, at a minimum:

(i) The minor's presenting needs, strengths, and rehabilitation expectations and responsibilities;

(ii) A description of needed and desired program services and interventions and staff responsible for implementation;

(iii) A description of how the needed and desired skills and supports will help the minor to be successfully maintained in the home or community, and manage the minor's psychiatric disorder;

(iv) Rehabilitation goals in measurable terms, and target dates for each goal; and

(v) If appropriate, identification of, recommendations for, and collaboration with, other services to support the minor's rehabilitation, including but not limited to mental health treatment, residential services, and somatic care; and

(c) That is reflective of the minor's overall plan of care.

(2) Individual Treatment and Rehabilitation Plan (ITRP). In collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP.

(3) Rehabilitation Plan Review. As frequently as necessary, as determined by a minor's rehabilitation coordinator, and, at a minimum of every 3 months, the rehabilitation coordinator, in consultation with the minor, shall:

(a) Review and record in the minor's medical record:

(i) The minor's progress toward the accomplishment of previously identified rehabilitation goals;

(ii) Goal changes, based on a review of the minor's progress;

(iii) Changes in interventions, as appropriate; and

(iv) Progress toward the reduction of functional behavioral impairments and restoration of specific age-appropriate skills;

(b) Communicate promptly the results of the review to:

(i) Relevant program staff;

(ii) The minor's parent or guardian, if appropriate;

(iii) With proper consent, community mental health programs providing services to the minor; and

(iv) With proper consent, the referring licensed mental health provider; and

(c) If the minor's service needs change, provide and document in the minor's record:

(i) The suggested changes in rehabilitation goals and services; and

(ii) Staffing and support services required by the change.

(4) Signature of the IRP Plan and Reviews.

(a) The following shall sign agreement with the IRP and ITRP reviews:

(i) The minor;

(ii) The minor's rehabilitation coordinator; and

(iii) The minor's parent or guardian, if appropriate.

(b) If the minor is unwilling to sign an agreement with the IRP and ITRP reviews, the minor's rehabilitation coordinator shall:

(i) Verify the minor's verbal agreement with the IRP and ITRP reviews;

(ii) Document the rationale for the minor's refusal to sign; and

(iii) Obtain the agreement and signature of agreement of the minor's parent or guardian.

(c) In addition, for an ITRP, at least two mental health professionals, who collaborate about the minor's treatment, shall sign the IRP and ITRP reviews, including:

(i) The minor's rehabilitation coordinator, and if the rehabilitation coordinator is not a mental health professional, the mental health professional who supervises the rehabilitation coordinator; and

(ii) The minor's treating mental health professional;

(d) If the minor is receiving medication prescribed through an outpatient mental health clinic (OMHC), the minor's rehabilitation coordinator shall provide the OMHC psychiatrist with a copy of the minor's IRP and ITRP reviews.

D. Continuing Evaluation.

(1) Contact Notes. Staff shall document:

(a) Each contact with or about the individual, including, at a minimum:

(i) The date;

(ii) The start and end time of services, if not documented in a readily accessible billing document;

(iii) The minor's chief medical complaint or reason for the visit;

(iv) The delivery of services specified by the IRP or ITRP;

(v) A brief description of the service provided; and

(vi) A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title.

(2) Progress Summary Notes. At a minimum, each month, the rehabilitation coordinator shall record in the minor's medical record a progress summary note that includes:

(a) The staff member's assessment of the minor's progress toward goal achievement in measurable terms;

(b) The minor's assessment of progress toward goal achievement; and

(c) Justification for the need for ongoing PRP services.

(3) If at least one contact note described in §D(1) of this regulation includes the information outlined in §D(2) of this regulation, the monthly progress summary note is not required.

(4) The rehabilitation coordinator shall document that the minor's needs and progress are promptly communicated to:

(a) Staff involved in the implementation of the IRP or ITRP; and

(b) The minor's parent or guardian, if appropriate; and

(c) With proper consent, other community mental health programs providing services to the minor.

Md. Code Regs. 10.21.29.06