(1) In addition to any clinical records required in ARM 37.85.414 or elsewhere in these rules, the licensed mental health center's CSCT program must maintain the following records for youth with serious emotional disturbance (SED):
(a) a written referral cosigned by the parent(s) or legal representative/guardian, which documents the reason for the referral;
(b) a signed verification indicating the parent(s) or legal representative/guardian has been informed that Medicaid requires coordination between CSCT, home support services, and outpatient therapy;
(c) a copy of the clinical assessment which documents the presence of SED;
(d) the individualized treatment plan for CSCT;
(e) daily progress notes from each team member that document individual therapy sessions and other direct services provided to the youth and family throughout the day including:
(i) when any therapy or therapeutic intervention begins and ends; and
(ii) the sum total number of minutes spent each day with the youth.
(f) 90-day treatment plan reviews; and
(g) discharge plan.
(2) In addition to (1), beginning July 1, 2014, youth records must also include the child and adolescent needs and strengths (MT CANS) assessment results.
(3) In addition to any clinical records required in ARM 37.85.414 or elsewhere in these rules, records for youth referred to CSCT regardless of their diagnosis as described in ARM 37.87.1803(4) must include the following:
(a) a written referral, signed by the person referring the youth and by the parent(s)/legal representative/guardian, which documents the reason for the referral;
(b) progress notes for each individual therapy session and other direct services provided to the youth and family throughout the day; and
(c) discharge plan with referral to additional services, if appropriate.
(4) Records for youth referred to CSCT and denied acceptance into the program must include the following:
(a) a written referral with the reason for the referral; and
(b) documentation detailing the reason for the denial.