a) Within 3 days following admission, a service needs evaluation or rehabilitative assessment shall be completed to determine the child's or youth's mental health needs and treatment. The assessment shall include a face-to-face interview with the child or youth, and direct contact with persons having first-hand knowledge of the child's or youth's symptoms and/or maladaptive behavior that led to the admission. This assessment will also include, at a minimum:

1. 1) Identifying information;
2. 2) Extent, nature and severity of presenting problems;
3. 3) Personal and family history, including the history of mental illness in the family;
4. 4) Cognitive functioning;
5. 5) History of mental health treatment;
6. 6) Present level of functioning, including social adjustment and daily living skills;
7. 7) Legal status of the child or youth;
8. 8) Level of education;
9. 9) Previous employment, acquired vocational skills and activities/interests;
10. 10) History of and/or current alcohol or chemical dependency;
11. 11) Previous and current psychotropic medications, last physical examination and any known medical problems; and

12. 12) Resource availability.

    The needs evaluation or rehabilitative assessment shall be reviewed and approved by the medical director.

b) Within 5 days following admission, the master individual treatment or rehabilitative services plan (ITP or RSP) shall be developed by a secure child care facility multi-disciplinary team with participation of the child or youth, the parents and/or Guardian ad Litem, the caseworker, the Department gatekeeper, clinical staff from the pre-admission placement, and clinical staff from the post-discharge target placement. The ITP or RSP shall include the DSM-IV or ICD-9-CM diagnosis determined by the medical director or designated psychiatrist. The ITP or RSP shall include, at a minimum, the following information:

1. 1) Overall goals of treatment;
2. 2) Specific mental health or rehabilitative services to be provided;
3. 3) Goals and objectives (if an ITP);
4. 4) Expected outcomes;
5. 5) Frequency or duration;
6. 6) Responsible staff;
7. 7) Precautions for high risk behavior;
8. 8) Specialized behavior modification programming;
9. 9) Summary of physician orders (including medications); and
10. 10) Criteria for discharge and step-down to a non-secure living arrangement.

e) Medicaid community mental health services (with the exception of assessment and crisis intervention) shall be provided following the assessment and shall be consistent with the treatment or services plan. Services can only be provided by individuals possessing the required qualifications for each discrete service as defined by 59 Ill. Adm. Code 132 (Medicaid Community Mental Health Services Program). These services include:

1. 1) Individual, Group or Family Therapy (ITP only);
2. 2) Psychotropic Medication Administration, Monitoring and Training (ITP only);
3. 3) Individual, Group or Family Counseling;
4. 4) Individual or Family Social Rehabilitation;
5. 5) Individual or Group Rehabilitative Stabilization;
6. 6) Developmental Rehabilitative Services;
7. 7) Client-centered or Rehabilitative Consultation;
8. 8) Intensive Family-based Services; and
9. 9) Case Management Services.

f) Secure child care facilities are required to have a written plan of utilization review. Utilization review activities shall be ongoing on a quarterly basis and designed to assess through individual case review the appropriateness of:

1. 1) Admission to Medicaid Community Mental Health Services;
2. 2) Intensity/level of services; and
3. 3) Continued services.

g) In order to document mental health and rehabilitative services, the secure child care facility shall maintain a clinical record for each child or youth. The clinical record shall include:

1. 1) Identifying information, including the child's or youth's preferred mode of communication and the communication requirements of any other persons involved in the child's or youth's case (i.e., parents, siblings, foster parents, etc.);
2. 2) Documentation of consent for mental health services;
3. 3) Assessment and reassessment reports;
4. 4) A current ITP or RSP, progress notes and reviews;
5. 5) Documentation concerning the prescription and administration of psychotropic medications;
6. 6) Documentation of missed appointments;
7. 7) Documentation of child or youth movement (referral or transfer) to or from the provider's programs or to or from other providers;
8. 8) Documentation to support services rendered for which reimbursement is claimed;
9. 9) Comprehensive services provided on a daily basis;
10. 10) Periodic reviews of child or youth progress;
11. 11) A record of the child's or youth's major accidents or incidents that occur at the site, and when the child's or youth's placement is terminated; and
12. 12) A discharge summary documenting the outcome of treatment.