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<regulation prefix="Regulation" num=".07" citation="COMAR 10.21.26.07" title_num="10" subtitle_num="21" chapter_num="26" heading="Treatment Planning and Evaluation.">
  <paragraph num="A.">
    <text>Individual Treatment Plan (ITP).</text>
    <paragraph num="(1)">
      <text>Treatment Team. At a minimum the following shall participate as members of an individual's RCS program treatment team:</text>
      <paragraph num="(a)">
        <text>The designated treatment coordinator;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Relevant RCS staff providing services to the individual; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>When available, relevant staff from other agencies currently providing services to the individual.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Individual Treatment Plan. Within 24 hours of placement in an RCS program, based on the screening evaluation under Regulation .05C of this chapter, the initial evaluation under Regulation .06A of this chapter, the assessment under Regulation .06B of this chapter, and the psychiatric diagnosis under Regulation .06C of this chapter, the treatment team shall prepare an ITP:</text>
      <paragraph num="(a)">
        <text>In collaboration with:</text>
        <paragraph num="(i)">
          <text>The individual;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>For a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>When appropriate and with proper consent, the individual's family and others involved in the individual's care;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>That includes, at a minimum:</text>
        <paragraph num="(i)">
          <text>The psychiatric diagnosis as provided in Regulation .06C of this chapter;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A description of the individual's current behavior, symptoms, and level of functioning that includes the individual's presenting strengths, needs, and treatment expectations and responsibilities;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>When relevant to the individual, a description of the family's or significant others' needs and strengths;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Mental health treatment goals, including the plan for transition and discharge, to be accomplished during an individual's residence in an RCS program, which are outcome oriented and stated in behavioral, measurable terms; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>The anticipated length of stay in the RCS program; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>That specifies treatment strategies, including:</text>
        <paragraph num="(i)">
          <text>Recommended modality and frequency of interventions, including, if appropriate, case management services;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Target dates for goal achievement;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The designation of RCS staff responsible for implementing the elements of the plan;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>Scheduled daytime activities, if any, such as a partial hospitalization program (PHP), psychiatric rehabilitation program (PRP) on-site or off-site services, and school services; and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>When appropriate, identification of, recommendations for referral to, and collaboration with, other services to support the individual's treatment.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Signature of the ITP.</text>
      <paragraph num="(a)">
        <text>The individual or, for a child, the parent or guardian shall sign or tape record agreement or disagreement with the ITP and reviews.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A child's primary caretaker, if other than the parent or guardian, shall sign or tape record acknowledgment of the ITP and reviews.</text>
      </paragraph>
      <paragraph num="(c)">
        <text>In addition, the following shall sign the ITP and reviews:</text>
        <paragraph num="(i)">
          <text>The individual's treatment coordinator;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>When there is an RCS psychiatrist, the RCS psychiatrist; and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>When there is a mental health professional, the mental health professional.</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Discharge Before the ITP. When an individual is discharged within 24 hours of admission to RCS, if the treatment team has not developed an ITP, the treatment coordinator shall document, in the individual's medical record, a brief description of the goals established and interventions employed.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Continued Evaluation.</text>
    <paragraph num="(1)">
      <text>Contact Notes. In order to assure that services to an individual are timely and appropriate, staff shall document in the individual's medical record contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the individual, including the dates, locations, and types of contacts.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Progress Summary Notes. The individual's treatment coordinator shall document or assure that staff document in the individual's medical record a daily progress summary note that includes:</text>
      <paragraph num="(a)">
        <text>A description of progress toward goals;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Changes in goals and interventions based on the review of progress; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The rationale for the changes.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>