Initial Face-To-Face Diagnostic Assessment to ensure proper and prompt diagnosis, the Mental Health Professional licensed and authorized by the Practice Act of the state where services are provided, no later than second visit must formulate and document in the medical record a diagnosis and the rational for the diagnosis based on initial face-to-face diagnostic assessment of the individual using the forms provided by the agency and any other tool medically necessary to ensure accuracy that fulfills all requirement of the State Program and Practice rules and regulations otherwise will document the rational for not complying with this section. All initial diagnostic face-to-face assessment must be conducted by a MENTAL HEALTH PROFESSIONAL TEAM headed and directed by the Medical Director or any other Psychiatrist assigned by the medical director (in case of more than one psychiatrist employed by the agency) and must include the Multi Disciplinary Team (MHP) members of a Licensed Professional Counselor and Licensed Social Worker and/or Clinical Nurse authorized by the Practice Act of the State to provide direct care services prescribed by the psychiatrist.
The final decision regarding the assessment is the prerogative of the psychiatrist leading the assessment team. Whereas, the Medical Director or any other Psychiatrist is not present during any initial diagnostic face-to-face assessment and at a minimum one member of the Mental Health Professional Team is licensed and authorized by the Practice Act of the State to formulate diagnosis, the Team must on or before the second visit meet with the Medical Director or any other psychiatrist assigned by the Medical Director to confirm the diagnosis. One member of the Multidisciplinary Team must be clinically privileged and credentialed by the Program Director and licensed and authorized by the State Practice Act to do so before the Team can formulate diagnosis.
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