14-118 C.M.R. ch. 5, § 15 - OPERATIONAL PRACTICES

15.1 Administration of Services.

15.1.1 Service Descriptions. Each program shall be specifically named and described in policy.

15.1.2 Contracted services. When an agency or program offers services through another provider, a contract agreement shall exist. This agreement shall be updated as changes occur. The agency shall ensure that services provided through a contract agreement comply with these rules and any contractual requirements.

15.1.3 Program Manager. The agency shall designate an individual as program manager, having overall responsibility for the operation of each program.

15.1.3.1 the duties of the program manager shall be clearly described in the written job description, including minimum qualifications, responsibilities and lines of authority.

15.1.3.2 nothing in these rules prohibits the sharing of managers between programs, if the programs are adequately managed.

15.1.4 Population Served. Characteristics of the population served shall be specifically defined for each program.

15.1.5 Reporting requirements. Agencies licensed/certified to provide substance abuse treatment shall submit such data as may be required by the Office of Substance Abuse, in the form and format specified, and within time frames requested.

15.2 Provision of Services to Clients.

15.2.1 Client Records. A client record shall be maintained for each client. Each program shall describe the format and content for records in the program policy and procedure manual.

15.2.1.1 The client record describes the client's medical health and mental health status at the time of admission, the services provided and the client's progress in the program, and the client's medical health and mental health status at the time of discharge.

15.2.1.2 The client record shall provide information for the review and evaluation of the treatment provided to the client.

15.2.2 All programs must be in compliance with Federal Confidentiality Regulations as outlined in 42 CFR Chapter 1, Subchapter A, Part 2, et seq. and amendments thereof.

15.2.2.1 Client records shall be maintained in a secure room, locked file cabinet, safe, or other similar container when not in use.

15.2.2.2 There shall be a written plan describing methods and procedures used to ensure confidentiality of client records.

15.2.2.3 There shall be a written plan to address security of active and inactive records, including access and removal from storage.

15.2.2.4 There must be a written plan for disposition of client records in compliance with Federal Confidentiality Regulations in case of program closure.

15.2.2.5 Client records shall be preserved for a minimum of 6 years except in the case of a minor, where they shall be kept for 6 years following the client's 18th birthday.

15.2.2.6 Upon admission, all clients must be provided with a written summary of client rights regarding confidentiality, as described in 42 CFR Chapter 1, Subchapter A, Part 2, et seq. and documented in the client record.

15.2.2.7 Electronic records. The use of electronic health records by the agency must comply with all applicable state and federal regulatory standards including the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91 and its implementing regulations (HIPAA). There shall be a plan for back-up of electronic record systems, if used.

15.3 Client Record. The client record shall include but not be limited to:

15.3.1 identification data, including name, address, telephone number, and date of birth;

15.3.2 reports from referring sources;

15.3.3 identification of collateral providers for SA, MH, and/or medical conditions, releases of information for contacting those providers, and documentation of communication with those providers. It shall also include releases for referral sources and family members.

15.3.4 results of the client's clinical assessment;

15.3.5 a statement signed by the client declaring his/her knowledge of the fee schedule, program rules, expectations, and client rights;

15.3.6 updated treatment plans and treatment plan reviews including any co-occurring disorder problems and goals;

15.3.7 progress notes, which must be related to specific problems or goals on the treatment plan and serving as the basis for evaluating treatment outcomes. This shall include but not be limited to the following:

15.3.7.1 documentation of implementation of the treatment plan;

15.3.7.2 documentation of all treatment rendered to the client;

15.3.7.3 descriptions of changes in the client's conditions, his/her response to treatment, and, as appropriate, the response of significant others to his/her treatment;

15.3.7.4 the date, signature, and professional qualifications of the individual making the entry in the client record.

15.4 Closed record. Each closed client record shall also contain:

15.4.1 a discharge summary which describes the client's course of treatment, program completion status, and the client's condition at discharge. The discharge summary shall make reference to the client's progress toward planned goals as listed on the treatment plan;

15.4.2 a treatment follow-up plan (See Section 15.10).

15.4.3 Whenever appropriate to the client's treatment the client record shall additionally include, but not be limited to:

15.4.3.1 family assessment as part of the process leading to the development of the individual treatment plan;

15.4.3.2 correspondence pertinent to the case;

15.4.3.3 signed consent forms for release of information, which must comply with Federal Confidentiality Regulations, and which, at a minimum must specify:

15.4.3.3.1 the entities from which and to which information is provided;

15.4.3.3.2 the purpose for which the information is requested, which must be related to treatment;

15.4.3.3.3 the scope and content of information requested (such as medical records, work records, etc.);

15.4.3.3.4 the period during which the release is valid. The period shall not exceed 365 consecutive calendar days;

15.4.3.3.5 the acquisition of dated signatures from parents of children or guardians when one has been appointed if the child lacks capacity because of extreme youth, or mental or physical incapacity, as per 42 CFR Chapter 1, Subchapter A, Part 2, et seq.;

15.4.3.3.6 the mechanism to withdraw consent for the release of information;

15.4.3.3.7 prohibition on re-release statement.

15.4.3.4 referrals for service to other agencies, including reasons for referral.

15.4.4 Program policies will include a plan to ensure legibility and integrity of entries to records. At a minimum, the policy must address:

15.4.4.1 corrections to records, prohibiting the use of correction fluid, tapes, labels and similar techniques and devices;

15.4.4.2 the prohibition of back-dating entries;

15.4.4.3 a provision for the use of late entries to records, which must include the use of a phrase identifying the entry as late;

15.4.4.4 a requirement for an easily recognizable date for every entry;

15.4.4.5 signatures and identification of persons making entries to records, including professional credentials.

15.5 Admission Policies. Every program shall have written admission policies and procedures that shall include:

15.5.1 criteria for determining the eligibility of individuals for admission. The program shall have no criteria establishing an arbitrary barrier to admission based on psychiatric diagnosis, psychotropic medication, psychiatric history, medical history or disorder, or Medication Assisted Treatment (MAT). Assessment for admission shall be based on determining the individual needs and capabilities of the client,and the capacity for those needs to be addressed within the framework of the program;

15.5.2 provision for an assessment that concludes that the treatment required by the client is appropriate to the level and restrictions of care provided by the program components, and that the treatment can be appropriately provided by the program;

15.5.3 procedures to make clients aware of program philosophies and rules and regulations;

15.5.4 a fee schedule, which shall be fully explained upon admission;

15.5.5 procedures to ensure that those clients refused treatment shall be informed of reasons for denial and a record is maintained of those refusals and reasons.

15.5.6 Re-admission.There shall be written policies delineating conditions for re-admission and for denial of same, which shall ensure that persons shall not be denied re-admission solely because they:

15.5.6.1 have withdrawn from treatment against clinical advice on a prior occasion;

15.5.6.2 have relapsed during an earlier treatment for either a mental disorder or a substance abuse if they are sufficiently stable for the care level provided by the program.

15.5.7 Appeal. There shall be a written procedure for clients who wish to appeal any adverse judgments on admission.

15.5.8 Waiting Lists. All treatment programs must maintain a log or register listing individuals actively seeking treatment whenever a program's service capacity has been reached. If such a listing is needed, it must be monitored. Individuals are appropriately placed on a waiting list when they meet screening and eligibility criteria for services of the program.

15.5.8.1 If required as defined above, waiting list procedures shall:

15.5.8.1.1 assure individuals are screened and referred or prioritized for admission according to a consistently applied needs criteria;

15.5.8.1.2 document the treatment requested and needs presented by the individual;

15.5.8.1.3 identify service needs of individuals based on available data;

15.5.8.1.4 identify and note referrals made matching the individual's needs to appropriate community resources;

15.5.8.1.5 be described in a program's written waiting list procedures.

15.6 Coordination of Care: Referrals and Collaboration.

15.6.1 The program shall have written policies and procedures to facilitate client referral and coordination of services either with other providers or between different service components of the agency. Such policies shall include procedures for coordination with mental health and medical providers if-such services are applicable to the goals of the treatment plan:.

15.6.1.1 Service coordination procedures shall specify the requirements for obtaining releases of information, the required frequency of communication, and documentation of coordination. Treatment plan reviews shall include input from significant collaborative care partners whose input is clinically necessary to the implementation of the treatment plan. This input may be presented by the collaborator in person, by phone presence at the treatment planning meeting, by prior contact with the collaborator's input dated and noted in writing in the file by the primary counselor, or in a written, signed note submitted by the collaborating provider.

15.6.1.2 Service coordination procedures shall have specific procedures for coordination of care during mental health crisis, including mechanisms for informing mental health crisis providers, transporting clients in crisis safely, maintaining communication during the crisis evaluation, and following through on interventions when the client returns to the program.

15.6.2 Referral process. Procedures shall be established to ensure completion of the referral process under the following conditions:

15.6.2.1 when it is determined that a client is inappropriate for admission to the program but is still in need of care;

15.6.2.2 when the client is in need of examinations, assessments, and consultations which are not within the professional domain or expertise of the staff;

15.6.2.3 when the client is in need of special treatment services.

15.6.3 Monitoring waiting lists and referrals. There shall be written policies and procedures for monitoring the prioritization of the agency waiting list(s) and the referral process to other treatment programs and services.

15.6.4 Screening. Program staff shall screen clients for unmet medical and mental health needs and complement the substance abuse plan of care with appropriate referrals for this care and shall follow procedures for continuing coordination of care.

15.7 Clinical Assessment.

15.7.1 For each client there shall be a complete assessment that concludes that the treatment required by the client is appropriate to the level and restrictions of care provided by the program component, and that the treatment can be appropriately provided by the program. An initial assessment must be completed prior to development of the treatment plan.

15.7.1.1 All assessments must include a mental health screening to determine whether a client's presenting signs, symptoms or behaviors may be influenced by co-occurring mental health issues. The screening must identify whether there is a need for a complete assessment of the mental health condition. A mental health assessment may be completed by a staff member whose licensed scope of practice permits assessment and diagnosis.

15.7.1.2 When a client is referred for a mental health assessment, or when an earlier mental health assessment report has been provided, or when a mental health assessment has recently been performed by another provider, there must be specific policies to incorporate that assessment information into the substance abuse record, and integrate it into the service plan in the SA program.

15.7.2 The assessment shall include, but is not limited to:

15.7.2.1 History of alcohol and drug use, including:

15.7.2.1.1 age of onset

15.7.2.1.2 duration

15.7.2.1.3 patterns

15.7.2.1.4 consequences

15.7.2.1.5 family usage

15.7.2.1.6 types of previous treatment

15.7.2.1.7 response to previous treatment

15.7.2.2 Strengths. A description of strengths including specific description of periods of time of previous sobriety, including the status of co-occurring conditions during that period. The description shall identify successful strategies and interventions utilized by the client to achieve success and identify needs in the following categories:

15.7.2.2.1 physical health

15.7.2.2.2 medication

15.7.2.2.3 allergies

15.7.2.2.4 nutrition

15.7.2.2.5 mental health, including psychiatric diagnoses and medications, as well as emotional and psychological issues

15.7.2.2.6 psychological

15.7.2.2.7 crisis intervention needs

15.7.2.2.8 family history

15.7.2.2.9 current home situation

15.7.2.2.10 physical, emotional, sexual, and domestic abuse

15.7.2.2.11 social supports

15.7.2.2.12 legal

15.7.2.2.13 financial

15.7.2.2.14 housing

15.7.2.2.15 vocational

15.7.2.2.16 educational

15.7.2.2.17 leisure and recreational interests

15.7.2.2.18 spirituality and religion

15.7.2.2.19 military

15.7.2.3 Assessments, and any addenda to assessments, should also include:

15.7.2.3.1 a summary;

15.7.2.3.2 an evaluation of the information;

15.7.2.3.3 documentation of previous and current mental health diagnoses, if appropriate, and current substance abuse diagnoses, including a discussion of how those two diagnoses currently impact and interact with one another;

15.7.2.3.4 signature and credentials of assessor and date signed.

15.8 Individual Treatment Plan.

15.8.1 An individually written treatment plan shall be maintained for each client.

15.8.2 The plan shall be based on a comprehensive assessment of the client's needs, which includes, but is not limited to information gathered in an assessment, as listed above.

15.8.3 An initial treatment plan shall be developed within 72 hours following admission to a-residential program, or within 3 sessions following admission to an outpatient care program, an intensive outpatient program [IOP], or a program based within a facility operated by the Maine Department of Corrections.

15.8.3.1 A comprehensive treatment plan, updating the initial treatment plan, shall be completed according to the schedule in 15.8.5.3 below.

15.8.4 Comprehensive treatment plans must contain the following elements:

15.8.4.1 problems to be addressed during treatment;

15.8.4.2 measurable long-term treatment goals that relate to problems identified in the assessment;

15.8.4.2.1 if indicated, goals related to any co-occurring disorder are stated in terms of that mental health condition's impact or effect on the substance abuse disorder. Mental health counseling may be provided if there is an appropriately credentialed staff member present and if the MH condition is treated as a part of the goals related to the SA disorder in terms of its effect or impact on the SA disorder.

15.8.4.3 measurable short-term goals leading to the completion of the long-term goals;

15.8.4.3.1 time frames for the anticipated dates of achievement/completion of each goal, or for reviewing progress toward goals.

15.8.4.3.2 specification and description of the indicators used to assess the individual's progress.

15.8.4.4 documentation of the treatment procedures proposed to assist the client in achieving these goals, including:

15.8.4.4.1 type and frequency of services to be provided.

15.8.4.4.2 referrals for needed services that are not provided directly by the program.

15.8.4.4.3 coordination of care requirements to help client integrate outside services

15.8.4.5 documentation of participation by the client in the treatment planning process, as evidenced by the client's signature on the treatment plan, or the reason why the client did not participate;

15.8.4.6 a description of any tests ordered and/or performed by the program and the results;

15.8.4.7 the clinician's signature, dated, with the clinician's credentials noted; and

15.8.4.8 participation of outside mental health, substance abuse, or medical providers as indicated.

15.8.5 Review of treatment plan. The treatment plan shall be reviewed and updated during the course of treatment.

15.8.5.1 This review shall:

15.8.5.1.1 document the degree to which the client is meeting his/her treatment goals;

15.8.5.1.2 modify existing goals or establish new ones as necessary.

15.8.5.2 The updated plan shall be signed by counselor and client at time of review.

15.8.5.3 The plan shall be reviewed at least:

15.8.5.3.1 every week in a program of 30 days duration or less;

15.8.5.3.2 every month for programs of 31 to 180 days;

15.8.5.3.3 every 3 months for programs in excess of 180 days;

15.8.5.3.4 every 3 months of outpatient treatment.

15.9 Discharge Policies and Procedures.

15.9.1 Every program shall have written discharge policies and procedures. These shall include:

15.9.1.1 a policy that states that no client is automatically discharged for using substances or for displaying symptoms of a co-occurring disorder. Discharge shall be based on the client's needs and the program's ability to meet those needs or on another cause for discharge as set out in these rules;

15.9.1.2 a policy that establishes a method for determining what additional interventions might be required or appropriate to help a client who displays symptoms of the client's disorders, particularly when co-occurring disorders are present;

15.9.1.3 procedures for planning the client's discharge in consultation with the client when one of the following conditions is met:

15.9.1.3.1 documentation that the client has received optimum benefit from treatment and further progress requires either the client's return to the community or the client's referral to another type of treatment program;

15.9.1.3.2 the client has achieved the indicators of the treatment plan that reflect the critical goal of treatment which may be one or more of the following:

15.9.1.3.2.1 medical stability;

15.9.1.3.2.2 recognition and understanding of the substance abuse problem;

15.9.1.3.2.3 development of skills to enable the client to increase life functioning and reduce the risk of relapse;

15.9.1.3.3 policies and procedures to be followed for discharge in the event that a client leaves the program against medical advice or has been administratively discharged from the program;

15.9.1.3.4 a requirement that the administrator (or designee) shall refer the person to another facility/program for treatment when appropriate;

15.9.1.3.5 procedures to encourage the client to agree to follow-up care after discharge;

15.9.1.3.6 a statement describing indicators to be used in determining successful program completion;

15.9.1.3.7 procedures for ensuring that clients who require assistance in obtaining supportive services or additional care shall have assistance from the program staff in making arrangements;

15.9.1.3.8 a statement that the staff shall make reasonable provisions for transportation to another facility/program, or to the client's home, even if the client leaves against clinical advice or receives an administrative discharge;

15.9.1.3.9 procedures to assist clients in obtaining shelter when needed. ;

15.9.1.3.10 procedures to ensure that clients with COD needs are linked with appropriate follow up for the client's mental health condition after discharge, whether discharge is routine or administrative.

15.9.2 Appeal procedure. Each program shall establish a written procedure for clients who wish to appeal any adverse judgments on program discharge.

15.10 Treatment Follow-up.

15.10.1 Programs shall develop written follow-up plans for all clients who are discharged from the treatment program.

15.10.1.1 The plan shall describe the program's responsibility for facilitating the transfer of the client to follow-up treatment services, other identified professional services, or a client support system.

15.10.1.2 The plan shall be in accordance with the client's reassessed needs at the time of discharge or transfer.

15.10.1.3 The plan shall be developed with the participation of the client and, where indicated, family, guardians or significant other.

Notes

14-118 C.M.R. ch. 5, § 15