Individualized Treatment Plan

(1) A Facility shall develop an individualized treatment plan (ITP) for each patient within thirty (30) days of admission. The ITP shall be developed in accordance with peer reviewed medication assisted treatment guidelines, developed by nationally recognized organizations, such as SAMHSA and the American Society of Addiction Medicine or the Tennessee Nonresidential Buprenorphine Treatment Guidelines. The initial and comprehensive assessments listed in 0940-05-35-.06 shall be completed, unless extenuating prohibitive circumstances exist, prior to the finalization of an initial ITP. Any significant findings from the initial or comprehensive assessments that impact the service recipient’s success in treatment and recovery shall be documented and addressed in the ITP. The ITP, at minimum, shall contain: S.M.A.R.T. goals for identified service needs of the patient, listing of the services provided in-house (including but not limited to: office visit, counseling, case management, drug screen), external services and the frequency of those in-house and external services. The Facility may use alternative treatment planning methods provided that the methodology is evidence-based and provides similar details to that of the S.M.A.R.T. goals as defined by these rules. The initial ITP and all reviews shall be signed, either in person, electronically, or by documented verbal acknowledgment, by the service recipient, qualified counseling provider, and program provider. (2) Medical care, including referral for necessary medical service, and evaluation and follow-up of patient complaints, shall be compatible with current and accepted standards of medical practice. All patients shall receive a physical exam, in accordance with federal and state controlled substance prescribing laws, medical evaluation at least annually as part of the initial assessment. A physical exam shall then be offered, either by the Facility or through a referral, as clinically indicated. Subsequent physical exams shall be documented in the medical record. Any physical examination shall be consistent with 42 CFR 12 requirements. The program provider shall record the results of the examinations and tests in the patient’s medical record. Any significant findings of the physical exam or other testing that may complicate a patient’s treatment at the Facility shall be included in the patient’s medical record. (3) Each Facility shall take steps to ensure that a comprehensive range of rehabilitative services, including vocational, educational, legal, mental health, alcoholism, and social services, are made available to the patients who demonstrate a need for such services. The Facility can fulfill this responsibility by providing support services directly or by appropriate referral. Support services that are recommended and/or utilized shall be documented in the patient’s medical record. Each Facility shall have policies for matching a patient’s needs to treatment. (4) If the patient experiences a return to drug use, his or her ITP shall document evidence of intensified services provided. Such evidence may include, but is not limited to, a “move back” to more intensive phases of treatment (as detailed by 0940-05-35-.10), an increase in individual or group counseling session(s), or more frequent drug screens. MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES (5) A patient’s ITP shall be reviewed at least every six (6) months and a discussion shall be held with the patient regarding his or her continued desire to remain in the program for maintenance treatment. Alternatives such as medically supervised withdrawal shall be presented to the patient at the time of the discussion and documented in the patient’s medical record. The patient shall sign and date a statement on the ITP indicating that she or he wishes to remain within the program in a maintenance phase. If the patient wishes to enter medically supervised withdrawal, the ITP shall reflect that choice.