Section 17b-262-824 - Need for service(a) Each client's care shall be under the direction of a physician directly employed by or under contract with the clinic. The physician shall authorize the care provided and periodically review the need for continuing care.(b) Psychiatric diagnostic evaluations shall be provided by an allied health professional who is permitted to conduct such evaluations under the applicable clinic licensure category.(c) The psychiatric diagnostic evaluation shall be used in formulating the plan of care and shall be completed for each client. The evaluation shall contain the following components: (1) The client's mental status;(2) Psychosocial history or updated psychosocial history for clients who have previously been in the provider's care;(3) Psychiatric or substance abuse history or updated psychiatric or substance abuse history for clients who have previously been in the provider's care;(4) Current medications, if indicated, medication history, or updated medication history for clients who have previously been in the provider's care;(5) Orders for and medical interpretation of laboratory or other medical diagnostic studies, if indicated;(6) The initial diagnosis, functional status and formulation; and(7) Treatment recommendations or further disposition of the client.(d) If treatment is recommended, a plan of care shall be developed.(e) The physician shall review the evaluation and plan of care and sign the plan of care and periodic reviews of the plan of care assuring that the services are medically necessary.(f) If treatment is not recommended, the physician shall sign the evaluation.(g) The plan of care shall, at a minimum, meet the requirements of the individualized care plan as described in: section 19a-495-550(k)(2)(C) of the Regulations of Connecticut State Agencies; individualized program plan described in section 19a-495-570(m)(6) of the Regulations of Connecticut State Agencies; or individualized treatment plan as described in section 17a-20-42 to 17a-20-43, inclusive of the Regulations of Connecticut State Agencies, as appropriate to the licensure of the service.(h) A psychiatric office consultation shall be billed only by a physician or advanced practice registered nurse. When a psychiatric office consultation is the only service provided by the clinic, only a written note is required as documentation and a plan of care is not necessary. If an advanced practice registered nurse provides the service, the written note shall be cosigned by a physician.(i) The evaluation and plan of care shall be made a part of the client's medical record.(j) Care planning shall be individualized and coordinated to meet the client's needs.Conn. Agencies Regs. § 17b-262-824
Effective October 9, 2013