Current through Register Vol. 51, No. 19, September 20, 2024
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.
