Individualized Treatment Plan

(1) A Facility shall develop an Individualized Treatment Plan (ITP) for each service recipient within thirty (30) days of admission. Each service recipient shall be involved in the development and review of their ITP. The initial ITP and all reviews shall be signed, either in person, electronically, or by documented verbal acknowledgement, by the service recipient, qualified counseling provider, and program provider. ITPs shall document the following: (a) A consistent pattern of substance use treatment services and medical care appropriate to the individual service recipient’s needs; and (b) S.M.A.R.T. goals discussed and agreed upon by the qualified counseling provider, program provider and the service recipient. The Facility may use alternative treatment planning methods provided that the methodology is evidence-based and provides similar details to those of the S.M.A.R.T. goals as defined by these rules. (2) The admission requirements of Rule 0940-05-42-.06 shall be completed prior to the development of an ITP. (3) Medical care, including referral for necessary medical service, and evaluation and follow-up of service recipient complaints shall be compatible with current and accepted standards of medical practice. All service recipients shall receive a physical examination at least annually. All other medical procedures performed at the time of admission shall be reviewed by the medical staff on an annual basis, and all clinically indicated tests and procedures shall be repeated. The medical director or program provider shall record the results of the annual medical examination and review of service recipient medical records in each service recipient’s medical record. (4) In recognition of the varied medical needs of service recipients, any case histories, ITPs, short-term withdrawal management plans, and discharge plans shall be reviewed at least every ninety (90) days for service recipients in treatment less than one (1) year and at least every six (6) months for service recipients in treatment more than one (1) year. This review will be conducted by the medical director or program provider along with the primary qualified counseling provider and other appropriate members of the treatment team involved in the service recipient’s treatment. This review shall also include an assessment of the current dosage, schedule, and the rehabilitative progress of the individual, as part of a determination that additional medical services are indicated. If this review results in a determination that additional or different medical or behavioral health services are indicated, the Facility shall ensure that such services are made available to the service recipient, either at the Facility or by referral to the appropriate medical professional. Any referrals shall be documented in the service recipient’s medical record and followed up on as appropriate. (5) When the program provider prescribes other controlled substances to service recipients in the Facility, the Facility shall ensure that such prescription is in compliance with all applicable statutes and regulations and with current and accepted standards of medical practice. Such prescriptions shall not be issued to any service recipient unless the program provider first sees the service recipient and assesses the service recipient’s potential for misuse of such medications. MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (6) As part of the rehabilitative services provided by the Facility, each service recipient shall be provided with individual and group counseling appropriate to their needs. The frequency and duration of counseling provided to service recipients shall be in conformity with Rule 0940- 05-42-.14 and be consistent with the ITP. ITPs shall indicate a specific level of counseling services needed by the service recipient as part of the rehabilitative process. (7) All service recipients shall receive HIV and hepatitis risk reduction education appropriate to their needs. (8) When appropriate, the Facility shall provide each service recipient information regarding enrollment in a vocational education program, engaging in a vocational activity (vocational evaluation, education, or skill training), or assisting the service recipient in efforts to seek gainful employment. Deviations from compliance with these requirements shall be explained in the service recipient’s medical record. Each Facility shall take steps to ensure that a comprehensive range of rehabilitative services, including vocational, educational, legal, mental health, treatment for other substances of misuse, and social services, are made available to the service recipients who demonstrate a need for such services. The Facility can fulfill this responsibility by providing support services directly or by appropriate referral. Support service(s) recommended and utilized shall be documented in the service recipient’s medical record. (9) All Facilities will develop and implement policies for matching service recipient’s needs to treatment. These policies may include treatment phasing in which the intensity of medical, counseling, and rehabilitative services provided to a service recipient is individualized for each service recipient depending upon the service recipient’s phase of treatment. (10) If the service recipient experiences a return to drug use, their ITP shall document evidence of intensified services. Such evidence shall include, but is not limited to, an increase in individual or group counseling session(s) and a reduction in the service recipient’s take-home privileges. (11) The program providers shall initiate and lead a discussion regarding patient readiness to taper down or taper off treatment medications employed in the patient’s treatment with each patient no later than one (1) year after initiating treatment and then every six (6) months thereafter or at any time upon the patient’s request. Documentation of this discussion shall be included in the patient’s ITP. Nothing in this part shall be construed to mean that patients should be forced to taper down or off of treatment medications.