(a) Assessment and documentation. At the first routine face-to-face or telemedicine contact with an individual seeking routine care services, as described in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services,) a QMHP-CS with appropriate supervision and training must perform an assessment of the individual. The assessment must be documented and must include:
  (1) the individual's identifying information;
  (2) completion of the appropriate uniform assessment(s) and assessment guideline calculations;
  (3) present status and relevant history, including education, employment, housing, legal, military, developmental, and current available social and support systems;
  (4) co-occurring mental illness, emotional disturbance, substance abuse, chemical dependency, or developmental disorder;
  (5) relevant past and current medical and psychiatric information, which may include trauma history;
  (6) information from the individual and LAR (if applicable) regarding the individual's strengths, needs, natural supports, describe community participation, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;
  (7) if the individual is an adult without an LAR, the needs and desire of the individual for family member involvement in treatment and mental health community services;
  (8) the identification of the LAR's or family members' need for education and support services related to the individual's mental illness or emotional disturbance and the plan to facilitate the LAR's or family members' receipt of the needed education and support services;
  (9) recommendations and conclusions regarding treatment needs; and
  (10) date, signature, and credentials of staff member completing the assessment.
(b) Diagnostics. The diagnosis of a mental illness must be:
  (1) rendered by an LPHA, acting within the scope of his/her license, who has interviewed the individual, either face-to-face or via telemedicine;
  (2) based on the DSM;
  (3) documented in writing, including the date, signature, and credentials of the person making the diagnosis; and
  (4) supported by and included in the assessment.
(c) Provision of services. The LMHA, MCO, and provider must require each provider to implement procedures to ensure that individuals are provided mental health community services based on:
  (1) the department's uniform assessment and utilization management guidelines;
  (2) medical necessity as determined by an LPHA; and
  (3) health management needs as determined by a physician, physician assistant, or registered nurse.
(d) Prerequisites to provision of services.
  (1) Routine care services. For routine care services, before providing mental health community services to an individual, the provider must:
    (A) obtain authorization from the department or its designee for the type(s), amount, and duration of mental health community services to be provided to the individual in accordance with the appropriate uniform assessment and utilization management guidelines;
    (B) obtain a determination of medical necessity from an LPHA; and
    (C) in collaboration with the individual and their LAR (if applicable), develop a treatment plan for the individual that includes a list of the type(s) of mental health community services authorized in accordance with subparagraph (A) of this paragraph.
  (2) Crisis services. For crisis services, as described in §412.321 of this title (relating to Crisis Services), a provider must deliver services in accordance with the utilization management guidelines and authorization of services and timeframes described in §412.318(c) of this title (relating to Utilization Management). A diagnosis is not required when services are delivered in crisis situations.
(e) Content and timeframe of treatment plan. Each provider must develop a written treatment plan, in consultation with the individual and their LAR (if applicable), within 10 business days after the date of receipt of notification from the department or its designee that the individual is eligible and has been authorized for routine care services.
  (1) At minimum, a staff member credentialed as a QMHP-CS is responsible for completing and signing the treatment plan. The treatment plan must reflect input from each of the disciplines of treatment to be provided to the individual based upon the assessment. The treatment plan must include:
    (A) a description of the presenting problem;
    (B) a description of the individual's strengths;
    (C) a description of the individual's needs arising from the mental illness or serious emotional disturbance;
    (D) a description of the individual's co-occurring substance use or physical health disorder, if any;
    (E) a description of the recovery goals and objectives based upon the assessment, and expected outcomes of the treatment in accordance with paragraph (2) of this subsection;
    (F) the expected date by which the recovery goals will be achieved;
    (G) a list of resources for recovery supports, (e.g., community volunteer opportunities, family or peer organizations, 12-step programs, churches, colleges, or community education); and
    (H) a list of the type(s) of services within each discipline of treatment that will be provided to the individual (e.g., psychosocial rehabilitation, medication services, substance abuse treatment, supported employment), and for each type of service listed, provide:
      (i) a description of the strategies to be implemented by staff members in providing the service and achieving goals;
      (ii) the frequency (e.g., weekly, twice a month, monthly), number of units (e.g., 10 counseling sessions, two skills training sessions), and duration of each service to be provided (e.g., .5 hour, 1.5 hours); and
      (iii) the credentials of the staff member responsible for providing the service.
  (2) The goals and objectives with expected outcomes required by paragraph (1)(E) of this subsection must:
    (A) specifically address the individual's unique needs, preferences, experiences, and cultural background;
    (B) specifically address the individual's co-occurring substance use or physical health disorder, if any;
    (C) be expressed in terms of overt, observable actions of the individual;
    (D) be objective and measurable using quantifiable criteria; and
    (E) reflect the individual's self-direction, autonomy, and desired outcomes.
  (3) The individual and LAR (if applicable) must be provided a copy of the treatment plan and each subsequent treatment plan reviewed and revised.
(f) Review of treatment plan.
  (1) Each provider must:
    (A) review the individual's treatment plan prior to requesting an authorization for the continuation of services;
    (B) review the treatment plan in its entirety, as permitted under confidentiality laws by considering input from the individual, the individual's LAR (if applicable), and each of the disciplines of treatment;
    (C) determine if the plan is adequately addressing the needs of the individual; and
    (D) document progress on all goals and objectives and any recommendation for continuing services, any change from current services, and any discharge from services.
  (2) In addition to the required review under paragraph (1) of this subsection, a provider may review the treatment plan in the following instances:
    (A) if clinically indicated; and
    (B) at the request of the individual or the LAR (if applicable), or the primary caregiver of a child or adolescent.
  (3) Any time the treatment plan is reviewed, the provider must:
    (A) meet with the individual either face to face or via telemedicine to solicit and consider input from the individual regarding a self-assessment of progress toward the recovery goals, as described in subsection (e)(1)(E) of this section;
    (B) solicit and consider the input from each of the disciplines of treatment in assessing the individual's progress toward the recovery goals and objectives with expected outcomes, described in subsection (e)(1)(E) of this section;
    (C) solicit and consider input from the LAR (if applicable) or primary caregiver, if the individual is a child or adolescent regarding the level of satisfaction with the services provided; and
Cont'd...
(D) document all the input described in subparagraphs (A) - (C) of this paragraph.
(g) Revisions to the treatment plan. If, after any review of the treatment plan, the provider determines it does not adequately address the needs of the individual, the provider must appropriately revise the content of the plan.
(h) Discharge Summary. Not later than 21 calendar days after an individual's discharge, whether planned or unplanned, the provider must document in the individual's medical record:
  (1) a summary, based upon input from all the disciplines of treatment involved in the individual's treatment plan, of all the services provided, the individual's response to treatment, and any other relevant information;
  (2) recommendations made to the individual or their LAR (if applicable) for follow up services, if any; and
  (3) the individual's last diagnosis, based on the DSM.

Source Note: The provisions of this §301.353 adopted to be effective April 29, 2009, 34 TexReg 2603; amended to be effective February 19, 2017, 42 TexReg 561; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237