Intake, Admissions, And Discharges

(1) Prior to admission to the Facility, each prospective service recipient shall be evaluated by the medical director or program provider and clinical staff who have been determined to be qualified by education, training, and experience to perform or coordinate the provision of such assessments. The purpose of such assessments shall be to determine whether medication- assisted treatment will be the most appropriate treatment modality for the service recipient. MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES No prospective service recipient shall be processed for admission until it has been verified that the prospective service recipient meets all applicable criteria. (2) Except as otherwise authorized by law, no prospective service recipient shall be admitted for treatment without written authorization. If a prospective service recipient lacks the legal authority to consent for treatment, the Facility shall obtain consent from a parent, legal guardian, and/or legal representative in writing for admission to such treatment. Such consent shall be documented in the service recipient’s medical record. The following information shall be explained by a trained staff person to the service recipient and other consenters and documented in the service recipient’s file: (a) The Facility’s services and treatment; (b) The specific conditions that will be treated; (c) Explanation of treatment options, including maintenance treatment and short-term withdrawal management, if available, and clinic charges, including the fee agreement, signed by the prospective service recipient or the service recipient’s legal representative; and (d) The Facility’s rules regarding service recipient conduct and responsibilities. (3) A program provider shall document that treatment is medically necessary. The admissions and initial dosing decision ultimately rests with the medical director or a program provider, as applicable and allowed by federal and state laws, rules, and regulations. (4) A Facility shall only admit and retain service recipients whose known needs can be met by the Facility in accordance with its licensed Facility purpose and applicable federal and state laws, rules, and regulations. (5) Pregnant females with an opioid use disorder shall be given priority for admission and services when a Facility has a waiting list for admissions and it is determined that the health of the mother and/or unborn child is more endangered than is the health of other service recipients waiting for services. (6) No Facility shall provide incentives for referral of prospective service recipients to the clinic. (7) Initial Assessment. Within fourteen (14) days of admission, the Facility shall complete an initial assessment. The initial assessment shall focus on the service recipient’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 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; (b) Relevant health history (e.g., determination of chronic or acute medical conditions such as diabetes, renal disease, hepatitis, sickle cell anemia, tuberculosis, HIV exposure, sexually transmitted infections, chronic cardiopulmonary disease, and pregnancy); (c) A personal and family medical and mental health history; MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (d) A determination of currently prescribed medications; (e) A personal and family history of substance use; (f) A determination of current opioid use disorder; (g) Determination of length of opioid use disorder; (h) An observed drug screen in compliance with Paragraph 0940-05-42-.17(4); (i) A screening for sexually transmitted infections (STIs), tuberculosis, and other communicable diseases based on the medical director’s 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; (j) Other tests as determined to be necessary by the Facility’s policies and procedures or by the program provider (e.g., CBC, EKG, chest x-ray, hepatitis B, hepatitis C, HIV testing). Tests not directly conducted by the Facility at admission shall be conducted within seven (7) days after admission. The Facility is responsible for obtaining and maintaining documentation of required laboratory tests performed by an alternative provider. (k) A determination if the 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 service recipient’s medical record. (l) The Facility may utilize components of the initial assessment performed by an outside provider if conducted within fourteen (14) days of admission and obtained by the Facility within seven (7) days of admission. (8) Comprehensive Assessment. Within thirty (30) days of admission, the Facility shall have completed a comprehensive assessment. The comprehensive assessment shall include information obtained from 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 in the initial assessment; (b) A review of any outside medical records obtained by the Facility with the service recipient’s, or their legal representative’s, written consent; (c) A social and family history; (d) A criminal justice history, including any current criminal justice involvement; and (e) A psychosocial assessment that shall include information about the service recipient’s: 1. Motivation for treatment; MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES 2. Personal treatment goals; 3. Personal strengths; 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; (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. Use of tobacco and other nicotine products; 9. Previous behavioral health services, including: (i) Diagnostic information; (ii) Treatment information; and (iii) Efficacy of current or previously used medication; 10. Mental status; 11. Current level of functioning; 12. Need for, and availability of, social supports; 13. Adverse childhood experiences; 14. Level of education; and 15. Adjustment to disabilities/disorders. (9) At the time of admission, the Facility shall conduct an inquiry with the Central Registry in accordance with Rule 0940-05-42-.20. MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (10) Non-Admissions. The Facility shall maintain written logs that identify persons who were considered for admission or initially screened for admission but were not admitted. Such logs shall identify the reasons why the persons were not admitted and what referrals were made for them by the Facility. (11) Discharge and Aftercare Plans. A Facility shall complete an individualized discharge and aftercare plan for service recipients who complete their course of treatment. (a) Upon admission a Facility shall begin development of a service recipient’s discharge plan. (b) All discharge and aftercare plans shall include documentation that the Facility’s treatment team has discussed with the service recipient an individualized treatment plan appropriate to the service recipient’s discharge and aftercare plans. (c) The service recipient’s discharge planning shall include the development of a list of treatment resources available to the service recipient in their community. This list shall be developed in consultation with the service recipient, shall be in writing, and shall be made available to the service recipient upon discharge. The Facility shall assist the service recipient in obtaining the appropriate referral. (d) The discharge plan shall be completed within seven (7) days of 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 service recipient’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 service recipient not participating in discharge and aftercare planning shall be documented in the service recipient’s medical record. (e) Service recipients that have lost contact with the Facility for greater than thirty (30) days shall be discharged from the Facility and will require a new admission upon return.