<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.21.26.06" title_num="10" subtitle_num="21" chapter_num="26" heading="Evaluative Services.">
  <paragraph num="A.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>Describe the presenting problem and history of present illness;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Collect and evaluate relevant medical and mental health history, including, if any:</text>
      <paragraph num="(a)">
        <text>Previous inpatient and outpatient treatment; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A review of current medications and source of prescriptions;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Evaluate current mental status;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Either:</text>
      <paragraph num="(a)">
        <text>Formulate and document a psychiatric diagnosis and the rationale for the diagnosis; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Affirm the psychiatric diagnosis, not more than 1 year old, formulated by the referral source and documented in the individual's medical record; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>Identify needed treatment.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>Identify the individual's strengths, needs, and desires;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Assess the individual's level of functioning and availability of family and other social supports;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Complete an assessment that includes, at a minimum, a review of:</text>
      <paragraph num="(a)">
        <text>The individual's:</text>
        <paragraph num="(i)">
          <text>Legal status;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Housing status;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Current employment and economic status;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>History of substance abuse;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>History of physical or sexual abuse;</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>History of violence or assaultive behaviors;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>Natural support system;</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>Activities of daily living; and</text>
        </paragraph>
        <paragraph num="(ix)">
          <text>Interpersonal skills; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>For a child, in addition to the requirements of §B(3)(a) of this regulation, the child's:</text>
        <paragraph num="(i)">
          <text>Developmental status;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Educational history and current placement;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Involvement with other agencies;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Home environment; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>Family history and evaluation of the current family status, including legal custody status; and</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Initiate the process to determine who will provide the individual's mental health care and treatment upon discharge from crisis services.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>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.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Somatic Care.</text>
    <paragraph num="(1)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>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:</text>
      <paragraph num="(a)">
        <text>Assess the individual's general physical health;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Determine whether the individual requires a physical examination or somatic care follow-up; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Make appropriate referrals for services.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>