Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 21 - MENTAL HYGIENE REGULATIONS
Chapter 10.21.20 - Community Mental Health Programs-Outpatient Mental Health Centers
Section 10.21.20.07 - Treatment Planning and Documentation
Universal Citation: MD Code Reg 10.21.20.07
Current through Register Vol. 51, No. 19, September 20, 2024
A. Individual Treatment Plan (ITP).
(1) Initial ITP.
(a) Not later than the fifth visit after an
individual is enrolled in an OMHC and based on the assessment conducted under
Regulation .05B of this chapter, the treatment coordinator and the individual,
and if the individual is a minor, the minor's parent, guardian, or primary
caretaker if appropriate, shall develop an ITP in collaboration with:
(i) With proper consent, family or others
designated by the individual, and others involved in the individual's care;
and
(ii) Other OMHC staff, as
appropriate.
(b) The ITP
shall include, at a minimum:
(i) The
individual's diagnosis;
(ii) The
individual's presenting needs, strengths, recovery, and treatment expectations
and responsibilities;
(iii) A
description of needed and desired treatment and interventions to be provided,
specifying the modality, frequency, and responsible staff;
(iv) A description of how the needed and
desired treatment will help the individual to manage the individual's
psychiatric disorder and to support recovery;
(v) Short-term and long-term treatment goals
in measurable terms and target dates for each goal; and
(vi) If appropriate, identification of,
referral for, and collaboration with other services or child service agencies
and providers to support the individual's treatment and recovery, including but
not limited to mental health residential services, psychiatric rehabilitation
services, self-help organizations, vocational programs, substance abuse
services, the local department of social services, the local department of
juvenile services, schools, and somatic care.
(c) The content of the ITP shall be
communicated to:
(i) Relevant program staff;
and
(ii) With proper consent,
family or others designated by the individual and, if applicable, community
mental health programs providing services to the individual.
(2) ITP Review. As
frequently as necessary, as determined by the individual and the individual's
treatment coordinator, and at a minimum of every 6 months, the individual and
the treatment coordinator shall:
(a) Review
the ITP with the individuals identified under §A(1) of this
regulation;
(b) Based on the
review, record in the individual's medical record:
(i) An assessment of the individual's
progress toward the accomplishment of previously identified treatment goals
that incorporates the perspective of the individual served;
(ii) Goal changes based on a review of
progress;
(iii) Changes in
treatment strategies; and
(iv)
Changes in diagnosis, if any; and
(c) Communicate the results of the treatment
plan review to:
(i) Relevant program
staff;
(ii) With proper consent,
substance abuse treatment providers and primary care provider, as
appropriate;
(iii) With proper
consent, family or others designated by the individual and community mental
health programs providing services to the individual.
(3) Signature of the ITP and
Reviews.
(a) Except as provided in
§A(3)(b) of this regulation, the individual shall sign agreement with the
plan and reviews.
(b) If the
individual is unwilling to sign agreement with the plan and reviews, the
individual's treatment coordinator shall:
(i)
Verify the individual's verbal agreement with the plan and reviews;
and
(ii) Document the rationale for
the individual's refusal to sign.
(c) If the individual is a minor, the minor's
parent or guardian, or if other than the minor's parent or guardian, the
minor's primary caretaker shall sign agreement with the plan and
reviews.
(d) With proper consent,
family or others designated by the individual, including the individual's
caregivers, may sign the plan and reviews.
(e) At least two licensed mental health
professionals who collaborate about the individual's treatment, shall sign the
plan and reviews.
(f) If the
individual is receiving medication prescribed through the OMHC, an OMHC
psychiatrist, or Certified Registered Nurse Practitioner in psychiatry,
whomever prescribes the medication, shall sign the plan and reviews.
(4) Upon completion of an ITP or
ITP review, an individual's treatment coordinator shall assure that the
individual is offered a copy of the plan or review and document the
individual's acceptance or decline of the offer in the individual's medical
record.
(5) Individual Treatment
and Rehabilitation Plan (ITRP). Staff may combine the required elements of an
ITP and IRP in one document, the ITRP.
B. Continuing Evaluation and Treatment.
(1) Contact Note. Staff shall document each
contact with the individual, including, at a minimum:
(a) The date;
(b) The start time and either the duration or
the end time;
(c) The individual's
chief medical complaint or reason for the visit;
(d) The individual's mental status;
(e) The delivery of services specified by the
ITP;
(f) A brief description of the
service provided;
(g) The plan for
changes in treatment, if any;
(h)
The individual's progress toward treatment goals; and
(i) A legible signature and printed or typed
name of the licensed mental health professional providing care, with the
appropriate title.
(2)
The treatment coordinator shall document any significant changes or events,
including hospitalizations, that affect the individual's treatment.
(3) The treatment coordinator shall ensure
that the individual's needs and progress are communicated to:
(a) Staff involved in the implementation of
the ITP; and
(b) With proper
consent:
(i) Community mental health programs
providing services to the individual; and
(ii) Family or others designated by the
individual.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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