10.47.01.04

.04 Clinical Requirements.

A. Admission. The program:

(1) Shall upon request for admission:

(a) Establish an interview date that falls within 10 working days of the individual's initial contact;

(b) Refer or recommend another program to the individual; or

(c) Place the individual on a waiting list;

(2) Shall have a detailed description of patient placement criteria for admission to the program, including:

(a) Eligibility criteria, using guidelines such as the American Society of Addiction Medicine Patient Placement Criteria or other guidelines approved by the Administration; and

(b) Procedures for admission;

(3) Shall include in its admission procedures:

(a) An intake process;

(b) An emergency intake process, including a procedure to refer individuals who are not suitable for its program to a more suitable program;

(c) A procedure for developing and maintaining a waiting list; and

(d) A fee schedule; and

(4) May not admit a patient unless the individual meets the admission criteria of the American Society of Addiction Medicine Patient Placement Criteria or other guidelines approved by the Administration.

B. Assessment.

(1) A program shall prepare a comprehensive assessment for each patient, unless the patient is being readmitted to the same program or admitted to a different program within 30 days of the patient's last discharge, or has received an assessment by a licensed or certified clinician or program within 30 days, in which case the program may update the prior assessment.

(2) The comprehensive assessment shall assess the following areas:

(a) Physical health;

(b) Employment or financial support;

(c) Drug and alcohol;

(d) Treatment history;

(e) Legal;

(f) Family and social;

(g) Educational; and

(h) Mental health.

(3) Programs shall use the Addiction Severity Index as the standardized assessment instrument for adults, or an equivalent assessment instrument chosen by the Administration.

(4) Programs shall use the Problem Oriented Screening Instrument for Teenagers as the standardized screening instrument for adolescents, or an equivalent screening instrument chosen by the Administration.

(5) The initial physical health assessment shall meet the requirements of the appropriate level of treatment.

C. Treatment Plans.

(1) A program shall develop a written treatment plan, with the participation of the patient, based on the comprehensive assessment and patient placement criteria, that shall set forth:

(a) The patient's individualized needs, including:

(i) Socialization;

(ii) Alcohol and drug abuse or dependence;

(iii) Psychological;

(iv) Vocational;

(v) Educational;

(vi) Physical health;

(vii) Legal; and

(viii) Family; and

(b) Individualized interventions, including:

(i) Long-range and short-range treatment plan goals and objectives;

(ii) Strategy for implementation of treatment plan goals and objectives;

(iii) Target dates for completion of treatment plan goals and objectives;

(iv) A schedule of clinical services including individual, group, and, if appropriate, family counseling;

(v) Criteria for successful completion of treatment;

(vi) Referrals to ancillary services, if needed; and

(vii) Referrals to self-help groups, if recommended.

(2) If the alcohol and other drug counselor is unable to develop a treatment plan within the required time, the clinical director or the clinical supervisor shall:

(a) Determine the reason for a delay in development of a treatment plan;

(b) Document the reason in the patient's record; and

(c) Direct an appropriate clinical staff person to develop a treatment plan within 7 working days of the clinical director's or clinical supervisor's documentation of the delay.

(3) The length of stay in the program shall be based on the patient's level of illness severity and response to treatment.

D. Infectious Disease Education. Within the first 30 days of treatment, a program shall ensure and document in the patient record that human immunodeficiency virus, hepatitis, sexually transmitted diseases, and tuberculosis education was completed, including:

(1) Risk assessment;

(2) Risk reduction; and

(3) If appropriate, referral for counseling and testing.

E. Family Involvement and Utilization of Self-Help Groups.

(1) A program may provide education and support services to a patient's family directly or through referrals to appropriate community agencies.

(2) A program shall:

(a) Develop procedures for obtaining an assessment of the treatment needs of the patient's family;

(b) Provide access or referral to family counseling;

(c) Describe how family members are involved in the patient's recovery process; and

(d) Develop procedures to encourage ongoing active participation by the patient and the patient's family in self-help groups and support activities.

F. Referrals. Referral documentation shall include the:

(1) Reason for referral;

(2) Name of the individual;

(3) Referring program;

(4) Receiving program; and

(5) Final disposition of referral.

G. Discharge.

(1) A program shall complete a written discharge summary.

(2) The discharge summary shall include:

(a) The reason for admission;

(b) The reason for discharge;

(c) The individual's address;

(d) A summary of services delivered, including frequency and duration of services, and progress made;

(e) If appropriate, the diagnosis and prognosis at the time of discharge;

(f) Current medications, if applicable;

(g) Continuing service recommendations and summary of transition process; and

(h) The extent of the individual's involvement in the discharge plan.

(3) The discharge summary shall be completed within 30 days of the patient's discharge from the program.

(4) In the event of a patient's transfer from the program to another program, the discharging program shall complete a written transfer summary.

(5) The transfer summary shall include:

(a) The reason for admission;

(b) The reason for discharge;

(c) The individual's address;

(d) The diagnosis and prognosis at the time of discharge; and

(e) Current medications, if applicable.

(6) The transfer summary shall be completed at the time of the patient's discharge from the program.

H. Child and Adolescent Services.

(1) A parent or guardian of a child or adolescent, with the child or adolescent's consent, may apply on behalf of the child or adolescent for admission to a certified program.

(2) A program exclusively for children and adolescents shall:

(a) Maintain written treatment protocols providing for the needs of adolescents and children, emphasizing the use of family interventions;

(b) Provide for the educational needs of adolescents in compliance with local, State, and federal laws and regulations;

(c) Comply with criminal background requirements for all staff; and

(d) Meet any other requirements requested by the Administration.

(3) A program that admits children and adolescents:

(a) May not admit a child or adolescent into treatment unless the treatment plan indicates that the program is appropriate for the child or adolescent;

(b) Shall provide separate social, residential, dietary, and recreational activities for the child or adolescent, if appropriate;

(c) Shall obtain informed consent from the child or adolescent, or the parents or guardians for the child or adolescent, to be admitted to the program;

(d) Shall comply with criminal background requirements for all staff; and

(e) Shall meet any other requirements requested by the Administration.

(4) A program that does not admit children and adolescents shall:

(a) Identify in its program service plan the elements of the program that make treatment, care, and rehabilitation for children or adolescents contraindicated; and

(b) Meet any other requirements requested by the Administration.

(5) Programs that provide services to adults and permit the adult's children or adolescents to be present at the program shall verify that the children and adolescents:

(a) Receive proper supervision;

(b) Are appropriately enrolled in education services; and

(c) Have access to appropriate health care.

I. Medication Control and Staff Requirements.

(1) A program shall develop and implement a written policy and procedure governing the use of controlled dangerous substances and other drugs used by the program. The policies shall include:

(a) A list of controlled dangerous substances and other drugs administered, dispensed, or stored at the program;

(b) Procedures to account for and secure the drugs from time of order until dispensing;

(c) Computer security and accountability, if applicable;

(d) Other policy and procedures required by the Administration; and

(e) Procedures for all Level III programs to hold securely all take-home opioid therapy medication for patients who are on opioid maintenance therapy.

(2) A program shall dispense medications to the patient according to the instructions, supervision, and directions of the licensed physician.

(3) If staff observes an adverse reaction to medication, the program immediately shall contact a licensed physician or emergency medical service to ensure the patient receives treatment.

(4) Medication Errors.

(a) For a medication error regarding administration, dispensing, documentation, inventory, or storage, an appropriate clinical staff person shall complete a report at the time of the incident.

(b) The report shall be filed and brought to the immediate attention of the:

(i) Administrator; and

(ii) Medical director, if a medical director is employed by the program.

(5) Programs shall report the diversion of any controlled substance to the Administration as soon as the diversion is discovered.