Current through Register 1531, September 27, 2024
(A)
Intake Services. During intake, the clinic licensed to
provide mental health services must accumulate and record at least the
minimally required patient information necessary to facilitate evaluation and
diagnostic services and/or for referral to an appropriate professional person
or agency. This intake must include screening for any co-occurring substance
use disorder.
(B)
Evaluation and Diagnostic Services.
(1) Evaluation and diagnostic services must
be documented and shall include:
(a)
Identification of the patients presenting complaint or problem at the time of
evaluation;
(b) An assessment of
the current status and history of the patient's physical and psychological
health;
(c) Current and former
substance use disorder treatment, or any other related treatment, including
pharmacotherapy; and
(d) Current
and former social, economic, developmental, and educational functioning,
describing both strengths and needs.
The above assessment shall be conducted by health care
providers trained in completing such an evaluation, which includes
evidence-based, specialized training in the assessment of substance used
disorders, as appropriate to the patient's needs.
(2) After initiating a patient's evaluation,
but prior to completion, patient treatment may begin, provided that sufficient
information to initiate treatment for the presenting complaint or problem on
that day of services is obtained and that the evaluation is completed in a
reasonable timeframe. When appropriate, a diagnostic evaluation shall include
the finding of a formal mental status examination and a diagnosis.
(3) When the initial evaluation indicates
further assessment beyond the scope of the clinic's capabilities, the clinic
program must refer the patient to the appropriate health care provider,
pursuant to 105 CMR 140.520(F).
(C)
Treatment Planning
Services.
(1) The patient's
written treatment plan shall be appropriate to the patient's presenting
complaint or problem and based on information gathered during the intake,
evaluation and diagnostic process, including any substance use disorder
screening results.
The treatment plan must reflect the services delivered to
address the chief complaint or problem on the date of first presentation as
well as services rendered during subsequent encounters. As treatment
progresses, further assessment and diagnostic information must be gathered and
documented so as to inform longitudinal treatment planning.
(2) The treatment plan must include at least
the following information, as appropriate to the patient's presenting complaint
or problem:
(a) identified problems and needs
relevant to treatment and discharge expressed in behavioral, descriptive
terms;
(b) the patient's strengths
and needs;
(c) measurable treatment
goals addressing identified problems with time guidelines for accomplishing
goals;
(d) identified clinical
interventions, including pharmacotherapy, to obtain treatment goals;
(e) evidence of patient involvement in
formulation of the treatment plan;
(f) clearly defined staff responsibilities
and assignments for implementing the plan;
(g) the date the plan was last reviewed
and/or revised; and
(h) the
signatures and licenses and/or degrees of staff involved in the review and/or
revision.
(3) The
treatment plan must be revised as necessary to reflect current problems,
specific and concrete goals, and treatments.
(D)
Treatment
Services.
(1)
Case
Consultation, Psychotherapy, and Counseling Services. These
services must include case consultation, individual, group, couple, and family
therapies provided by and/or supervised by the mental health professionals
identified in
105 CMR
140.530(C). There must be
documentation of progress towards defined treatment plan goals as a result of
the clinical intervention(s).
(2)
Pharmacotherapy Services. These services must include,
but are not limited to, an assessment of the patient's psychiatric symptoms and
disorders, health status including medical conditions and medications, use or
misuse of alcohol or other substancesand prior experience with psychiatric
medications. Services also include medication prescribing, reviewing, and
monitoring by a prescriber working within the scope of their training and
license. The services may also include administration of medications in
accordance with a prescribing practitioner's order or prescription. The clinic
may contract with appropriately licensed individuals with the authority to
prescribe medications.
(3) When
necessary treatment services for a patient are beyond the scope of the clinic's
capabilities, the clinic program must refer the patient to the appropriate
health care provider, pursuant to 105 CMR 140.520(F).
(E)
Emergency
Services. Each clinic licensed to provide mental health services
must provide clinic coverage 24 hours aper day, seven days per week that
includes evaluation, diagnosis, and disposition services for an existing
patient's presenting crisis, including short-term intervention and/or referral,
and must have a written policy addressing emergency treatment referral for
patients and individuals pursuant to
105 CMR
140.305(A). Such coverage
must include telephone coverage that provides qualified professionals who are
available to talk with patients over the telephone during nonbusiness hours
and, if indicated, arrange for further care and assistance directly or through
referrals in real time.
(a) During nonbusiness
hours, a prerecorded message will not fulfill 105 CMR 140.520(E) requirement
for access to a qualified professional by phone.
(b) Clinics are expected to keep a current on
call roster of clinicians available to speak with patients at all times, as
well as information on available regional services.
(F)
Referral
Services. Each clinic licensed to provide mental health services
must have written policies and procedures that address the referral of patients
to the appropriate health care providers including, but not limited to,
substance use disorder providers, should the patient's identified health needs
exceed the scope of services provided by the clinic's mental health service.
Such policies and procedures must also address emergency referral, including
for voluntary and involuntary commitments to psychiatric hospitals.
(G) Other services not specifically listed in
105 CMR 140.520 that enhance and augment the required or adequate mental health
services, such as case management or community rehabilitation support, may be
but are not required to be provided by the licensed clinic.
