Admissions And Discharges And Best Practices Utilized

(1) Initial Screening. Prior to admission to the Facility, each prospective patient shall be evaluated by the medical director or program provider or staff who have been determined to be qualified by education, training, and experience to perform or coordinate the provision of such screening. The purpose of such screening shall be to determine, and document, MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES whether the patient meets the diagnostic criteria for an opioid use disorder as defined in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and whether the Facility will be the most appropriate treatment modality for the patient. No prospective patient shall be processed for admission until it has been verified that the patient meets all applicable criteria. (2) Initial Assessment. Within seven days of admission, the Facility shall complete an initial assessment. The initial assessment shall focus on the individual’s eligibility and need for treatment and shall provide indicators for the service recipient’s disease severity and the need for any appropriate referrals. Whenever possible and with service recipient written consent, the initial assessment shall include a family member or significant other to assist in the provision of accurate information and a full understanding and retention of instructions given to the service recipient. The initial assessment shall include, but not be limited to, the following: (a) A physical examination that includes a review of systems, vital signs, a pain assessment, and laboratory testing, unless otherwise specifically exempt pursuant to state or federal regulation, consistent with 42 C.F.R. § 12 (2025); (b) A past medical history; (c) A substance use history that includes type, frequency, and amount of substances used, including illicit substances, tobacco, and alcohol; (d) A list of currently prescribed or over-the-counter medications; (e) A personal and family history of substance use; (f) A confirmation of the opioid use disorder diagnosis; (g) An initial observed drug screen to identify the current use of drugs including, but not limited to, opioids (including fentanyl, buprenorphine, and methadone), amphetamines, cocaine, barbiturates, and benzodiazepines; (h) A screening shall be conducted for sexually transmitted infections (STIs) and tuberculosis. The medical director may screen for other communicable diseases based on their discretion. The Facility shall maintain a documented policy and procedure for screening for communicable diseases, which includes the process for screening methods used by the Facility and the process for providing referrals for patients for further communicable disease screening, testing, or treatment, as appropriate. Patient- specific factors that warrant a deviation from these rules or the Facility’s policy and procedures shall be documented in the patient’s medical record; (i) Any additional screening tests, such as pregnancy screenings, as necessary or appropriate; and (j) A determination if the prospective service recipient needs special services, such as treatment for alcohol use disorder or psychiatric services, and determination that the Facility is capable of addressing these needs either directly or through referral. If referral to an outside provider is deemed necessary, efforts of the Facility in making the referral shall be documented in the patient’s medical chart. (3) The Facility may utilize components of the initial assessment performed by an outside provider if conducted within 14 days preceding the admission and obtained by the Facility within 7 days of admission. MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES (4) Prior to receiving treatment at the Facility, the patient shall acknowledge in writing having received education on the following: (a) Treatment options, including detoxification, and the benefits and risks associated with each treatment option; (b) The risk of neonatal abstinence syndrome and use of voluntary long-acting reversible contraception for all female patients of child bearing age and potential; (c) Prevention and treatment of chronic viral illnesses, such as HIV and hepatitis C; (d) Expected therapeutic benefits and adverse effects of treatment medication; (e) Risks for overdose, including drug interactions with CNS depressants, such as alcohol and benzodiazepines, and relapsing after periods of abstinence from opioids; and (f) Overdose prevention and reversal agents. (5) A Facility shall only admit and retain patients whose known needs can be met by the Facility in accordance with its licensed program purpose and description and applicable federal and state statutes, laws, and regulations. (6) Drug dependent pregnant females shall be given priority for admission and services. (7) No Facility shall provide a bounty or other reward to a third party for referral of potential patients to the clinic. (8) Comprehensive Assessment. Within 30 days of admission, the Facility shall have completed a comprehensive assessment. The comprehensive assessment shall include information obtained by the patient, family members, friends, peers, and other collateral sources, where appropriate and with the service recipient’s written consent. The comprehensive assessment shall include, but not be limited to, the following: (a) A review of the information collected from the initial assessment; (b) Follow up tests as necessary or appropriate based on initial screening (e.g., CBC, EKG, chest x-ray, hepatitis B, hepatitis C, HIV testing, pregnancy testing). The Facility is responsible for obtaining and maintaining documentation of required laboratory tests performed by an alternative provider; (c) A review of any outside medical records obtained by the Facility with the service recipient’s written consent; (d) A social and family history; (e) A criminal justice history, including any current criminal justice involvement; and (f) A psychosocial assessment that shall include information about the service recipient’s: 1. Motivation for treatment; 2. Personal treatment goals; 3. Personal strengths; MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES 4. Individualized needs; 5. Urgent needs, including suicide risk; 6. Abilities and/or interests; 7. Presenting problems including a thorough analysis of the service recipient’s high- risk behaviors such as: (i) Licit and illicit drugs used, including alcohol, including; (I) Amount(s) and method(s) used; (II) Frequency of use; and (III) Duration of use; (ii) Symptoms of physical dependence or withdrawal; (iii) History of treatment for addictive behaviors; (iv) Adverse consequences of use; and (v) Inappropriate use of prescribed substances; 8. Previous behavioral health services, including: (i) Diagnostic information; (ii) Treatment information; and (iii) Efficacy of current or previously used medication; 9. Mental status; 10. Current level of functioning; 11. Need for, and availability of, social supports; 12. Adverse childhood experiences; 13. Adjustment to disabilities/disorders; and 14. Level of education. (9) Discharge and Aftercare Plans. A Facility shall complete an individualized discharge and aftercare plan for patients who complete their course of treatment. (a) All discharge and aftercare plans shall include documentation that the Facility’s qualified counseling providers and/or program providers have discussed with the patient an individualized medically supervised withdrawal plan appropriate to the patient. MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES (b) The patient’s discharge planning shall include the development of a menu of appropriate treatment resources available to the patient in his or her community. This menu shall be developed in consultation with the patient and shall be in writing and made available to the patient upon discharge. The Facility shall assist the patient in obtaining the appropriate referrals, as necessary. (c) The discharge plan shall be completed at the time of the patient’s discharge by the person who has primary responsibility for coordinating or providing for the care of the service recipient. It shall include a final assessment of the patient’s status at the time of discharge and aftercare planning. If applicable, parents or guardian, or responsible persons may participate in discharge and aftercare planning. The reason for any patient not participating in discharge and aftercare planning shall be documented in the patient’s medical record. (10) The Facility shall document when a patient discontinues services at an OBOT. Determination of the events that constitute a patient’s discontinuation of services at an OBOT shall be at the OBOT’s discretion. (11) If a patient is observed to have experienced multiple relapses, the Facility shall consider the appropriateness for a referral of the patient to more intensive levels of care, to include but not be limited to, intensive outpatient, methadone treatment, or residential substance use disorder treatment. The Facility’s consideration for a referral shall be documented in the patient’s medical chart. Considerations for subsequent referrals should be discussed in line with ITP review frequency, as outlined in 0940-05-35-.09(5).