(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 signed verification indicating the parent(s), legal representative, or guardian has been informed by the licensed mental health center that Medicaid requires coordination between CSCT, home support services, and outpatient therapy;

(b) a copy of the clinical assessment which documents the presence of SED;

(c) the individualized treatment plan for CSCT;

(d) 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.

(e) 90-day treatment plan reviews;

(f) discharge plan; and

(g) the Comprehensive School and Community Treatment Data Collection Template, that must be completed each March and September for each youth enrolled in CSCT and submitted to the Children's Mental Health Bureau by the licensed mental health center. The department adopts and incorporates by reference the Comprehensive School and Community Treatment Data Collection Template (form), dated November 1, 2021. A copy of this form may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT, 59604-4210 or at found at https://dphhs.mt.gov/dsd/CMB/.

(2) 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) progress notes for each individual therapy session and other direct services provided to the youth and family throughout the day; and

(b) discharge plan with referral to additional services, if appropriate.

(3) Records for youth referred to CSCT and denied acceptance into the program must include documentation detailing the reason for the denial.