(B) Evaluation and Diagnostic Services.

1. (1) Evaluation and diagnostic services must be documented and shall include:

   1. (a) Identification of the patients presenting complaint or problem at the time of evaluation;
   2. (b) An assessment of the current status and history of the patient’s physical and psychological health;
   3. (c) Current and former substance use disorder treatment, or any other related treatment, including pharmacotherapy; and
   4. (d) Current and former social, economic, developmental, and educational functioning, describing both strengths and needs. The above assessment shall be conducted by health care providers trained in completing

such an evaluation, which includes evidence-based, specialized training in the assessment of substance used disorders, as appropriate to the patient’s needs. (2) After initiating a patient’s evaluation, but prior to completion, patient treatment may begin, provided that sufficient information to initiate treatment for the presenting complaint or problem on that day of services is obtained and that the evaluation is completed in a reasonable timeframe. When appropriate, a diagnostic evaluation shall include the finding of a formal mental status examination and a diagnosis. (3) When the initial evaluation indicates further assessment beyond the scope of the clinic’s capabilities, the clinic program must refer the patient to the appropriate health care provider, pursuant to 105 CMR 140.520(F).

(C) Treatment Planning Services.

1. (1) The patient’s written treatment plan shall be appropriate to the patient’s presenting complaint or problem and based on information gathered during the intake, evaluation and diagnostic process, including any substance use disorder screening results. The treatment plan must reflect the services delivered to address the chief complaint or problem on the date of first presentation as well as services rendered during subsequent encounters. As treatment progresses, further assessment and diagnostic information must be gathered and documented so as to inform longitudinal treatment planning.

2. (2) The treatment plan must include at least the following information, as appropriate to the patient’s presenting complaint or problem:

   1. (a) identified problems and needs relevant to treatment and discharge expressed in behavioral, descriptive terms;
   2. (b) the patient’s strengths and needs;
   3. (c) measurable treatment goals addressing identified problems with time guidelines for accomplishing goals;
   4. (d) identified clinical interventions, including pharmacotherapy, to obtain treatment goals;
   5. (e) evidence of patient involvement in formulation of the treatment plan;
   6. (f) clearly defined staff responsibilities and assignments for implementing the plan;
   7. (g) the date the plan was last reviewed and/or revised; and
   8. (h) the signatures and licenses and/or degrees of staff involved in the review and/or revision.
3. (3) The treatment plan must be revised as necessary to reflect current problems, specific and concrete goals, and treatments.

(D) Treatment Services.

1. (1) Case Consultation, Psychotherapy, and Counseling Services. These services must include case consultation, individual, group, couple, and family therapies provided by and/or supervised by the mental health professionals identified in 105 CMR 140.530(C). There must be documentation of progress towards defined treatment plan goals as a result of the clinical intervention(s).
2. (2) Pharmacotherapy Services. These services must include, but are not limited to, an assessment of the patient’s psychiatric symptoms and disorders, health status including medical conditions and medications, use or misuse of alcohol or other substancesand prior experience with psychiatric medications. Services also include medication prescribing, reviewing, and monitoring by a prescriber working within the scope of their training and license. The services may also include administration of medications in accordance with a prescribing practitioner's order or prescription. The clinic may contract with appropriately licensed individuals with the authority to prescribe medications.
3. (3) When necessary treatment services for a patient are beyond the scope of the clinic’s capabilities, the clinic program must refer the patient to the appropriate health care provider, pursuant to 105 CMR 140.520(F).

(E) Emergency Services. Each clinic licensed to provide mental health services must provide clinic coverage 24 hours aper day, seven days per week that includes evaluation, diagnosis, and disposition services for an existing patient's presenting crisis, including short-term intervention and/or referral, and must have a written policy addressing emergency treatment referral for patients and individuals pursuant to 105 CMR 140.305(A). Such coverage must include telephone coverage that provides qualified professionals who are available to talk with patients over the telephone during nonbusiness hours and, if indicated, arrange for further care and assistance directly or through referrals in real time.

1. (a) During nonbusiness hours, a prerecorded message will not fulfill 105 CMR 140.520(E) requirement for access to a qualified professional by phone.
2. (b) Clinics are expected to keep a current on call roster of clinicians available to speak with patients at all times, as well as information on available regional services.