This chapter applies to programs organized to provide intensive, assertive mental health treatment and support services delivered by a multidisciplinary treatment team to an adult or a minor whose mental health treatment needs have not been met through routine, traditional outpatient mental health programs. Services are provided flexibly and in the various community settings determined by the needs of the individual. The purpose of mobile treatment services (MTS) is to enable the individual to: Remain in the community, thus reducing the individual's admissions to emergency rooms, inpatient facilities, or detention centers; and Achieve transition to less intensive outpatient services. In this chapter, terms have the meanings stated in COMAR 10.21.17. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing MTS if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter. The program director shall assure that services: Are therapeutic and are age and culturally appropriate; Are provided by MTS staff who: As determined by the program, are appropriately credentialed and privileged; and Are available: As indicated in the screening assessment or the individual's ITP, to deliver services at a time and in a setting agreeable to the individual served; and On an on-call basis, 24 hours per day, 7 days per week; Engage an individual who is unable or unwilling to use traditional mental health services by: Using an assertive approach in making services available and acceptable to the individual by: Identifying and addressing stressors that the individual identifies as priorities; Developing creative individualized approaches in an effort to engage the individual in services; and Recognizing that establishing a therapeutic relationship may take place over an extended period of time; and Being sufficiently flexible to allow for the delivery of service in the setting and at the time that is appropriate for the individual's needs; Establish between the individual and the MTS staff a therapeutic relationship that includes mutual development of short-term and long-term goals for the individual; Respect the individual's privacy at the individual's residence by: Except in an emergency, notifying the individual, in advance, of the time that MTS staff will visit the individual's home; Having private conversations; Obtaining the individual's permission to bring anyone else to the individual's home; and If requested, terminating a home visit; and Assist the individual to interact with agencies and others to: Have access to services and entitlements necessary to support adequate living conditions; Maintain continuity of care by coordinating access to various treatment and rehabilitation services; Promote community participation by engaging in age-appropriate social and recreational activities; and Access housing, if necessary. Eligibility. An individual is eligible for MTS if: Based on a screening assessment conducted according to the provisions of §B of this regulation, the individual would benefit from services that are: Directed at providing mental health treatment; and Available, by being delivered at a site that is accessible to an individual who: Is homeless; Has been unable or unwilling to use, on a continuing basis, community-based mental health services that are prescribed for the individual; or Is in an institution or inpatient facility and would be able to reside in a community setting if the individual received MTS and other appropriate support services; and The services are preauthorized by the Administration's administrative services organization (ASO), according to the provisions of COMAR 10.21.17.02-1A. Screening Assessment. Within 10 working days of receipt of a referral for MTS, the MTS mental health professional who is assigned to conduct screenings shall: Conduct a face-to-face screening assessment with the individual referred to assess the individual's: Needs, strengths, and available resources; and Willingness to participate in MTS; Meet with the individual in the individual's home or at a site that is most appropriate to the individual's needs and preferences; As appropriate and with proper consent, meet with the family members and significant others designated by the individual; and Unless the individual is referred to the Administration's ASO for alternative services under §B(2) of this regulation: Determine priority for enrollment based on acuity of the individual's need; and Arrange an appointment for a psychiatric evaluation, as described under Regulation .05A of this chapter. If, following the screening assessment under §B(1) of this regulation, the program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall, in writing, promptly: Inform the individual and, if the individual is a child, the parent or guardian, of the determination and the reason; With proper consent, notify the family or significant others designated by the individual of the determination and of any recommendations for other services; and Notify the CSA and the Administration's ASO for appropriate alternative referral. Admission. An MTS program shall admit an individual if the services are authorized, as needed, by the Administration's ASO, according to the provisions of COMAR 10.21.17.02-1A. Initial MTS Psychiatric Evaluation. Within 30 days of receipt of referral for MTS, the MTS psychiatrist, in collaboration with the individual's assigned treatment coordinator, shall conduct a face-to-face evaluation of the individual to: Collect and evaluate relevant history; Evaluate current mental status, including: The need for medication; and A review of current medications and source of prescriptions; Assess the individual's general physical health, and either: Perform a physical examination; Document a physical examination of the individual during the prior year; Refer the individual for a physical examination; or Waive the requirement that the individual have a physical examination and document the rationale for the waiver; Formulate and document the psychiatric diagnosis and the rationale for the diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record; In collaboration with the individual: Identify the individual's needs, strengths, and goals; and Assess the individual's level of functioning and availability of family and other social supports; Document the rationale for the determination that MTS are medically necessary; and Develop an initial brief plan of care. Diagnosis. As required under §A(4) of this regulation, the MTS psychiatrist shall conduct the evaluation and formulate and document the psychiatric diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record. An individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, may provide continuing psychiatric diagnosis. Individual Treatment Plan (ITP). Treatment Team. At least the following shall participate as members of an individual's MTS treatment team: The MTS psychiatrist or a third-year or fourth-year psychiatric resident who is supervised by the MTS psychiatrist; A licensed social worker; A registered nurse; The individual's treatment coordinator, as defined under Regulation .09 of this chapter; and When available, any other staff involved in providing services to the individual. Initial ITP. Before the 45th day after an individual is admitted to MTS, based on the screening assessment under Regulation .04B of this chapter and psychiatric evaluation under Regulation .05A of this chapter, the treatment team, under the direction of the treatment coordinator, in collaboration with the individual and, with proper consent, family members or significant others designated by the individual, shall prepare an ITP that includes: The psychiatric diagnosis; Description of the individual's current behavior and level of functioning that includes the individual's needs and strengths; When relevant to the individual, a description of the family's or significant others' needs and strengths; Short-term and long-term goals, including the plan for transitioning to traditional outpatient mental health services, that are outcome-oriented and that are stated in behavioral, measurable terms; Treatment strategies, including: Recommended type and frequency of interventions; The method of providing the services required under Regulation .06 of this chapter; and Target dates for goal achievement; and The designation of MTS staff responsible for implementing the elements of the plan. 3-Month ITP Review. At a minimum of every 3 months at a treatment team meeting, the individual's treatment coordinator, in collaboration with the individual, shall review the ITP and record in the individual's medical record: A description of progress toward the goals; Changes in goals and interventions based on the review of progress documented by the individual's treatment coordinator; and A statement validating the need for continued MTS. Signature of the ITP and ITP Reviews. The individual shall sign or tape record agreement or disagreement with the plan. The MTS psychiatrist and the individual's treatment coordinator shall sign the ITP and the ITP 3-month reviews. Continuing Evaluation. In order to ensure that services to an individual are timely and appropriate, the staff shall document in the individual's medical record: Contact notes, regarding all face-to-face and other clinically relevant contacts with or about the individual; and Progress summary notes, entered at least monthly by the individual's treatment coordinator, that include: A description of progress toward the goals; and Changes in goals and interventions based on the review of progress. Medication Services. Evaluation and Prescription. When prescribing medication for an individual, the MTS psychiatrist shall: Conduct a face-to-face evaluation of the individual; Through a medical history, evidence of a recent physical examination, records review, laboratory testing, or other appropriate measures, assure that there are no contraindications to the prescription of specific medications; Document in the individual's medical record the rationale for prescribing the medication; Explain to the individual or the individual's legal guardian both the benefits and the side effects of prescribed psychiatric medications before and, when appropriate, during treatment and document the explanation in the individual's medical record; and Order and monitor tests at medically recommended intervals and document the results in the individual's medical record. Administration. An individual licensed under Health Occupations Article, Annotated Code of Maryland, to administer medication may do so. A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of COMAR 10.27.11. Monitoring. When required by the individual's ITP, a member of the treatment team credentialed and privileged to do so shall provide the following services: Supporting the individual's self-administration of prescribed medication; To the extent possible, monitoring compliance with instructions appearing on the label; Reading the label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; Ensuring that each individual has secure, appropriate, and accessible space in which to store medications; Observing and documenting any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicating to the prescribing authority any problems that possibly may be related to the medication; and Reinforcing education on the role and effects of medication in symptom management. Education Regarding Medication. As required by an individual's ITP, a nurse, a physician, or other privileged and credentialed staff shall educate the individual and, with the individual's consent, the individual's family or significant others, by: Verifying the individual's understanding of the directions for administration of medication; and Providing information regarding: The role, effects, and importance of medication in symptom management; Expected benefits and expected side effects of prescribed medication; and Nutritional and dietary expectations and risks related to the individual's medication regimen. Independent Living Skills Assessment and Training. The MTS staff shall: In collaboration with the individual, assess the individual's level of functioning in the areas of: Community living skills, including but not limited to: Mobility training; and Money management; Activities of daily living, including: Meal planning and preparation; Personal hygiene; and Grooming; and Interpersonal and socialization skills, including: Communication; and Leisure and social activities; and Based on the assessment conducted under §B(1) of this regulation, provide rehabilitation activities to assist with and facilitate the individual's acquisition and improvement of independent living skills. Health Promotion and Training. To supplement and support the somatic health care provided by an individual's primary health care provider, the MTS psychiatrist or registered nurse shall carry out health promotion activities, including but not limited to: Monitoring of a chronic medical condition that is managed by a primary health care provider, including: Teaching on illness prevention and wellness maintenance; and Reinforcement of instructions given by the primary health care provider; Evaluating an acute problem to determine the most appropriate health care provider and referring the individual to the provider; and Assisting an individual to understand and carry out health-care-related behaviors, including activities related to diagnostic testing preparation and prescribed treatment for acute and short-term illness. When indicated in the individual's ITP, MTS staff shall provide basic health teaching in the following areas: Nutrition; Exercise; Dental care; Substance abuse prevention; and Prevention of injury and illness at home and in the community. MTS staff credentialed and privileged to do so shall provide training in communicable disease prevention, including prevention of sexually transmitted diseases and bloodborne pathogens, including HIV/AIDS. Interactive Therapies. MTS staff shall provide, as required in the individual's ITP, therapies, including individual, group, and family therapy focused on: Assessment and definition of problems; Planning and goal setting; Development of effective problem-solving techniques; Evaluation of progress; and Other issues raised by the individual. Crisis Intervention Service. The MTS treatment team shall provide to an individual who is receiving MTS a crisis intervention service that is: Designed to be implemented in the event of a crisis in the home or other setting in which the individual is involved; Explained in terms understandable to the individual; and Available, on an on-call basis, 24 hours per day, 7 days per week. Support, Linkage, and Advocacy. The MTS treatment team shall assure appropriate coordination with community and family resources that are considered essential to meeting the individual's identified needs, including but not limited to intervention and advocacy with: MTS staff and other community mental health and rehabilitation service providers; Mental health clinic and psychiatric rehabilitation programs; Social service agencies; Courts and detention centers; Providers of needed medical and dental services; Immediate and extended family members; For school age children, the educational system; and Recreational activities. Housing Development. The program director shall ensure that the program: Collaborates with the CSA in developing the CSA's plan for affordable, accessible housing in the community; Maintains information about available regular housing that is: Integrated throughout the community; Not limited as to length of stay, or conditional upon an individual's participation in mental health treatment or support services; and Within the price range that is affordable to individuals enrolled in the program; and In conjunction with the CSA: Attempts to develop financial resources to assist an individual temporarily in such circumstances as an individual's hospitalization or loss of job, benefits, or housemate; and Establishes priorities by which housing financial resources are allocated to individuals. Housing Needs Assessment. The program director shall ensure that program staff, in collaboration with the individual, conduct an assessment of: The individual's housing needs; and If the individual does not have housing that the individual considers adequate, the rehabilitative skills that the individual needs to obtain the housing of choice. Accessing and Sustaining Housing. The program director shall ensure that the program provides, as needed by and acceptable to the individual, services that are directed at: Assisting an individual in making choices about where and with whom to live by developing or restoring the basic social and living skills needed to: Link, when interested, with other individuals with similar interests and housing requirements; Evaluate financial resources, available natural supports, and needed and desired community services; Locate available properties and, when interested, negotiate acquisition; and Secure available financial entitlements and U.S. Department of Housing and Urban Development Section 8 and other types of housing financial assistance; Developing or restoring appropriate basic living skills and supports to keep housing, such as: Responsibilities for upkeep of the property and personal belongings; Maintaining an adequate supply of food and household goods; Development of community resources and natural supports; Housemate conflict resolution; and Landlord-tenant negotiations regarding such issues as rent, needed repairs, and complaints; and Additional support, as determined by the individual's need. Discharge Procedures. An MTS program may discharge an individual from MTS only when: The individual: Is unwilling to continue to accept MTS; Is admitted to an inpatient facility for longer than 3 months; or Moves from the area served by MTS; or The Administration's ASO determines that transition and discharge from MTS is medically appropriate. When an MTS program discharges an individual under §A(1)(a)(i) or (ii) of this regulation, the MTS program shall, as authorized: Permit the individual to re-enroll in MTS; and Make assertive efforts to re-enroll the individual. When an MTS program discharges an individual under §A(1)(a)(iii) of this regulation, the MTS program shall, when possible and as authorized, refer the individual for appropriate mental health and support services in the individual's community. When transition and discharge from MTS is authorized under §A(1)(b) of this regulation, the MTS treatment coordinator, in collaboration with an individual, shall: Document the individual's: Achievement of treatment goals; Anticipated needs for treatment and rehabilitation services; and Readiness for participation in outpatient mental health clinic (OMHC) or other appropriate outpatient mental health services, as demonstrated by keeping appointments, using transportation independently, obtaining and taking prescribed medications, and actively participating in treatment; and In consultation with the Administration's ASO, prepare a transition plan, according to the provisions of §B of this regulation. Transition Services. When the Administration's ASO authorizes a transition plan, the individual's treatment coordinator, in consultation with the Administration's ASO, shall: Arrange transition services in collaboration with: The individual; The treatment team; As appropriate and with proper consent, family members and significant others designated by the individual; and Designated transition service providers; Provide authorized MTS transition services, refer the individual for other appropriate services, and arrange to initiate authorized services before a planned discharge; With proper consent and as authorized by the Administration's ASO, facilitate the individual's transition to other appropriate services by: Inviting the designated provider or providers of mental health services to whom the individual has been referred to participate in the transition planning; Forwarding to the provider or providers a copy of the transition and discharge plan; and For a period of time based on the individual's needs, periodically meeting with the individual and the provider or providers, as necessary to facilitate transition; If the individual does not successfully complete transition, arrange, if authorized by the Administration's ASO, for the continuation of MTS; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). A provider of MTS shall ensure that the MTS staff includes, at a minimum: A program director who: Is a mental health professional; Is available to provide MTS administration and supervision: If fewer than 40 individuals are receiving services, for an amount of time calculated on the basis of 1/2 hour per week for each individual who is receiving services; or If 40 or more individuals are receiving services, 20 hours per week; Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17 and the day-to-day clinical responsibilities for MTS; Recruiting, hiring, training, and supervising staff; Developing and implementing the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; Ensuring that MTS are available to the individual, if needed, 24 hours per day, 7 days per week, and establishing on-call responsibilities; Ensuring continuity of care during the time that an individual is receiving MTS by evaluating caseloads and coordinating staff schedules; and Ensuring that transition services are provided; and May carry out any of the clinical and training duties of a mental health professional or other MTS staff; A psychiatrist who: Is involved, for an amount of time calculated on the basis of at least 1/4 hour per week for each individual who is receiving services, in: Consultation with MTS staff; and Evaluating and providing MTS; Ensures that MTS are provided in accordance with accepted standards of medical practice; Following a screening evaluation of an individual completed under Regulation .04B of this chapter, has an initial face-to-face contact with the individual, as required under Regulation .05A of this chapter, to: Formulate and document the psychiatric diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record; Assess medical needs; Confirm the medical necessity of MTS; When appropriate, order MTS for the individual; and Authorize the initial ITP; Is responsible for, at a minimum, the following: Evaluating the individual, face-to-face, at least every 3 months; As required under the provisions of Regulation .05C of this chapter, participating in the development, required periodic review, and signing of an individual's ITP; Prescribing medication and providing other medication services outlined in Regulation .06A of this chapter; Providing the appropriate treatment indicated in the individual's ITP; and Supervising psychiatric residents, if any, who provide MTS, including, if duties are delegated, providing, at least monthly, a review of the status of the individuals whom the resident is treating; May delegate the following duties to a third-year or fourth-year resident of an accredited program in psychiatry: Except for the initial 3-month evaluation, the periodic evaluations required under §B(4)(a) of this regulation; Participation in the development, required periodic review, and signing of an individual's ITP, required under §B(4)(b) of this regulation; If the resident is a licensed physician, prescribing medication and providing other medication services, as provided under §B(4)(c) of this regulation; and As provided in §B(4)(d) of this regulation, providing the appropriate treatment indicated in the individual's ITP; and May not delegate: The initial psychiatric evaluation; Formulation and documentation of the psychiatric diagnosis or affirmation of a psychiatric diagnosis that has been entered in the individual's MTS medical record; or Ordering of MTS for an individual; A registered nurse who: Is licensed under the provisions of Health Occupations Article, Title 8, Annotated Code of Maryland; Participates in MTS for an amount of time calculated on the basis of at least 1 hour per week for each individual who is receiving services; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties that the nurse is credentialed and privileged to perform, including but not limited to: Medication administration and other medication services outlined in Regulation .06A of this chapter; and Health promotion and training, as outlined in Regulation .06C of this chapter; At least one social worker who: Is licensed under the provisions of Health Occupations Article, Title 19, Annotated Code of Maryland; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties the social worker is credentialed and privileged to perform, including but not limited to: Interactive therapies, as outlined in Regulation .06D of this chapter; Support, linkage, and advocacy, as outlined in Regulation .06F of this chapter; and Discharge and transition services as outlined in Regulation .07 of this chapter; and At least one mental health professional who: May include the staff identified in §§C and D of this regulation; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties that the mental health professional is credentialed and privileged to perform, including but not limited to: Conducting the screening evaluation required under Regulation .04B of this chapter and participating in the initial psychiatric evaluation required under Regulation .05A of this chapter; According to the provisions of Regulation .05C of this chapter, reviewing and signing an individual's ITP; The duties outlined in Regulations .06 and .07 of this chapter that the mental health professional is licensed or credentialed and privileged to perform; When credentialed and privileged by the program to do so, functioning as the treatment coordinator for individuals who are receiving MTS; Supervising direct service providers; and Assuring that, before the provision of MTS and, as needed, on an in-service basis, appropriate training is provided to direct service providers. The program director shall assign to each individual who is receiving MTS a mental health professional who is the individual's treatment coordinator, and who shall: Assess the individual's needs by: Collaborating in the initial psychiatric evaluation conducted according to the provisions of Regulation .05A of this chapter; and Collecting and evaluating relevant history; Establish and maintain a therapeutic relationship; Direct the development of the ITP and required periodic updates, as outlined in Regulation .05C of this chapter; Ensure appropriate linkage with treatment services by providing: Outreach, which includes: Meeting with the individual in the individual's home or at a site that is most appropriate to the individual's needs and preferences; and Crisis intervention; Advocacy, which includes assisting the individual to acquire treatment and rehabilitation services acceptable to the individual and entitlements, housing, and other basic necessities; and Coordination of service plans with other agencies and providers; Monitor the progress of the individual by: Conducting periodic assessments of the individual's living situation; Conducting face-to-face assessments of the individual's mental status, including the individual's: Appearance; Behavior; Affect; Thought processes; Judgment; and Insight; and Maintaining progress summary notes, as required under the provisions of Regulation .05D(2) of this chapter; As required by the individual's ITP, provide interactive therapies delineated under Regulation .06D of this chapter; and When appropriate, recommend discharge and prepare, with the individual, a discharge plan, according to the provisions of Regulation .07 of this chapter. As needed, based on the number of individuals served, the program director may include on the MTS staff direct service providers who: May include the staff identified in Regulation .08C and D of this chapter; and As permitted under Health Occupations Article, Annotated Code of Maryland, perform assigned duties that the direct service provider is credentialed and privileged to perform. A provider of MTS shall base the capacity of the MTS program on the basis of one full-time treatment staff person for each 12 individuals served. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2188) Regulation .01C repealed effective August 24, 1998 (25:17 Md. R. 1360) Regulation .02-1 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .03F amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .04 amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .05 amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .06-1 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .07 repealed and new Regulation .07 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .08A amended effective August 24, 1998 (25:17 Md. R. 1360)