14-118 C.M.R. ch. 5, § 19 - SUBSTANCE ABUSE TREATMENT SERVICES
19.1
Medically Managed Intensive Inpatient Detoxification Programs (ASAM Level
IV-D).
19.1.1 Definition. Medically
managed intensive inpatient detoxification programs provide services to persons
who are experiencing severe withdrawal symptoms and therefore require full
medical acute care services in a twenty-four hour hospital setting. Services
include a biopsychosocial evaluation, medical observation, monitoring, and
treatment, counseling, and follow-up referral. Services shall be delivered in
an appropriately licensed/certified acute
care inpatient setting, adhering to medically-approved procedures and
protocols.
19.1.2 Services
provided. Medically managed intensive inpatient detoxification programs will
provide immediate medical evaluation and continued medical management,
including:
19.1.2.1 Highly individualized
biomedical, emotional, behavioral, and addiction treatment. This includes the
management of all concomitant biomedical, emotional, behavioral, and cognitive
conditions in the context of addiction treatment;
19.1.2.2 Availability of hourly or more
frequent nurse monitoring;
19.1.2.3
A range of cognitive, behavioral, medical, mental health, and other therapies,
to enhance the client's understanding of addiction, the completion of the
detoxification process, and referral for continuing treatment and
support;
19.1.2.4 Health education
services;
19.1.2.5 Services to
families and significant others;
19.1.2.6 Availability of specialized medical
consultation. Providers of detoxification services shall make and maintain
arrangements with external clinicians and facilities for referral of the client
for specialized services beyond the capability of the program;
19.1.2.7 Full medical acute care
services;
19.1.2.8 Intensive care,
as needed;
19.1.2.9 Nutritional
services, including special diets, as needed.
19.1.3 Staff.
19.1.3.1 Medically managed intensive
inpatient detoxification programs shall be staffed by physicians or physician
extenders who are available 24 hours a day as an active member of an
interdisciplinary team of appropriately trained professionals, and who
medically manage the care of the client.
19.1.3.2 A registered nurse or other licensed
and credentialed nurse shall be available for primary nursing care and
observation 24 hours a day.
19.1.3.3 An alcohol and drug counselor shall
be available 8 hours a day to administer planned interventions according to the
assessed needs of the client.
19.1.3.4 An interdisciplinary team of
appropriately trained clinicians shall be available to assess and treat the
client with a substance-related disorder, or an addicted client with a
concomitant acute biomedical, emotional, or behavioral disorder.
19.1.4 Client records.
19.1.4.1 Elements of the assessment and
treatment plan will include, but not be limited to:
19.1.4.1.1 A comprehensive nursing
assessment, performed at admission;
19.1.4.1.2 Approval of the admission by a
physician;
19.1.4.1.3 A record of a
comprehensive history and physical examination performed within 24 hours of
admission, accompanied by appropriate laboratory and toxicology tests OR the
evaluation of the records of a physical examination administered within the
preceding 7 calendar days prior to admission, by a physician or physician
extender;
19.1.4.1.4 An
addiction-focused history, obtained as part of the initial assessment and
reviewed by a physician during the admission process;
19.1.4.1.5 Sufficient biopsychosocial
screening assessments to determine placement, and for the individualized care
plan to address treatment priorities. This assessment must be completed as soon
as the client is medically stable, but no later than the fourth day of
admission, to include screening for history of abuse or trauma;
19.1.4.1.6 An individualized treatment plan,
including problem identification, treatment goals, measurable treatment
objectives, and activities designed to meet those objectives.
19.1.4.2 Other documentation will
include:
19.1.4.2.1 Progress notes entered by
clinical staff at least once in each 24 hour period that clearly reflect
implementation of the treatment plan and the client's response to treatment, as
well as subsequent amendments to the plan;
19.1.4.2.2 Detoxification rating scale tables
and flow sheets, as needed;
19.1.4.2.3 Physician services, documented in
the client record as they occur;
19.1.4.2.4 Notes of client progress entered
by nurses at least once each shift or every 8 hours;
19.1.4.2.5 A record of discharge/transfer
planning, beginning at admission.
19.1.5 Methadone detoxification. Persons
presenting symptoms of severe opiate withdrawal in a residential setting may
require the use of methadone to facilitate a successful withdrawal. The
administration of methadone to facilitate detoxification will require
compliance with a variety of Federal and State of Maine laws, and will also
involve oversight by Federal and State agencies to monitor compliance with
these laws. The detoxification process using methadone involves the reduction
of dosage from the stabilization dosage to a zero dosage upon discharge.
Methadone detoxification programs must meet the following requirements:
19.1.5.1 Programs using methadone must
include documentation of approval from and compliance with regulations of the
Substance Abuse and Mental Health Services Administration (SAMHSA), the Federal
Drug Enforcement Administration, the Maine State Pharmacy Board, and the Maine
Department of Health and Human Services, Division of Licensing and Regulatory
Services.
19.1.5.2 Also required is
proof of appropriate accreditation by the Joint Commission for the
Accreditation of Health Care Organizations, or the Commission on Accreditation
of Rehabilitation Facilities. Detoxification programs that employ the services
of a physician certified by the American Society of Addiction Medicine must
provide a copy of such certificate.
19.1.5.3 Programs using methadone must submit
de-identified client data to the Office of Substance Abuse on forms provided by
the office. This data will be made available only for research and program
evaluation functions.
19.2
Freestanding Residential
Detoxification Programs
(ASAM Level III 7-D/medically monitored inpatient detoxification).
19.2.1
Definition. Freestanding residential detoxification programs provide care to
persons whose withdrawal signs and symptoms indicate the need for 24-hour
residential care. Services include a biopsychosocial evaluation, medical
observation, monitoring, and treatment, counseling, and follow-up referral.
However, the full resources of an acute care general hospital or a medically
managed intensive inpatient treatment program are not necessary. Services must
be conducted in a freestanding or other appropriately licensed/certified healthcare or addiction treatment
facility.
19.2.2 Services provided.
The freestanding residential detoxification program will provide immediate
medical evaluation and continued medical management, including:
19.2.2.1 group therapies, and withdrawal
support;
19.2.2.2 Availability of
hourly or more frequent nurse monitoring;
19.2.2.3 A range of cognitive, behavioral,
medical, mental health, and other therapies, designed to enhance the client's
understanding of addiction, the completion of the detoxification process, and
referral for continuing treatment and support;
19.2.2.4 Health education services;
19.2.2.5 Services to families and significant
others;
19.2.2.6 Availability of
specialized clinical consultation and supervision for biomedical, emotional,
and behavioral and cognitive problems. Providers of detoxification services
shall make and maintain arrangements with external clinicians and facilities
for referral of the member for specialized services beyond the capability of
the program;
19.2.2.7 Direct
affiliation with other levels of care;
19.2.2.8 Ability to conduct or arrange for
appropriate laboratory and toxicology tests;
19.2.2.9 Nutritional services, including
special diets, as needed.
19.2.3 Staff.
19.2.3.1 Freestanding residential
detoxification programs shall be staffed by physicians or physician extenders
who are available 24 hours a day by telephone.
19.2.3.2 A registered nurse or other licensed
and credentialed nurse shall be available to conduct a nursing assessment on
admission.
19.2.3.3 A nurse shall
be on site at all times, and shall be responsible for overseeing the monitoring
of the client's progress and medication administration on an hourly basis, as
needed.
19.2.3.4 Appropriately
licensed and credentialed staff shall be available to administer medications in
accordance with physician orders. The level of nursing care must be appropriate
to the severity of client need.
19.2.3.5 Appropriately credentialed alcohol
and drug counselors shall provide evaluation and treatment services for
clients, and family support as needed.
19.2.3.6 An interdisciplinary team of
appropriately trained clinicians shall be available to assess and treat the
client and to obtain and interpret information regarding the client's needs.
The number and disciplines of team members are appropriate to the range and
severity of the client's problems.
19.2.4 Client records.
19.2.4.1 Elements of the assessment and
treatment plan will include, but not be limited to:
19.2.4.1.1 An addiction-focused history,
obtained as part of the initial assessment and reviewed by a physician during
the admission process;
19.2.4.1.2 A
record of a physical examination by a physician or physician extender,
performed within 48 hours of admission, accompanied by appropriate laboratory
and toxicology tests OR the evaluation of the records of a physical examination
administered within the preceding 7 calendar days prior to admission, by a
physician or physician extender;
19.2.4.1.3 Sufficient biopsychosocial
screening assessments to determine the level of care in which the client should
be placed and for the individualized care plan to address treatment
priorities;
19.2.4.1.4 An
individualized treatment plan, including problem identification, treatment
goals, measurable treatment objectives, and activities designed to meet those
objectives.
19.2.4.2
Other documentation will include:
19.2.4.2.1
Progress notes that clearly reflect implementation of the treatment plan and
the client's response to treatment, as well as subsequent amendments to the
plan;
19.2.4.2.2 Detoxification
rating scale tables and flow sheets, as needed;
19.2.4.2.3 Physician services, documented in
the client record as they occur;
19.2.4.2.4 Notes of client progress entered
by nurses at least once each shift or every 8 hours;
19.2.4.2.5 Notes of client progress entered
by clinical staff at least once in each 24 hour period;
19.2.4.2.6 A record of discharge/transfer
planning, beginning at admission.
19.2.5 Methadone detoxification. Persons
presenting symptoms of severe opiate withdrawal in a residential setting may
require the use of methadone to facilitate a successful withdrawal. The
administration of methadone to facilitate detoxification will require
compliance with a variety of Federal and State of Maine laws, and will also
involve oversight by Federal and State agencies to monitor compliance with
these laws. The detoxification process using methadone involves the reduction
of dosage from the stabilization dosage to a zero dosage upon discharge.
Methadone detoxification programs must meet the following requirements:
19.2.5.1 Programs using methadone must
include documentation of approval from and compliance with regulations of the
United States Food and Drug Administration, the Federal Drug Enforcement
Administration, the Maine State Pharmacy Board, and the Maine Department of
Health and Human Services, Division of Licensing and Regulatory
Services.
19.2.5.2 Also required is
proof of appropriate accreditation by the Joint Commission for the
Accreditation of Health Care Organizations, or the Commission on Accreditation
of Rehabilitation Facilities. Detoxification programs who employ the services
of a physician certified by the American Society of Addiction Medicine must
provide a copy of such certificate.
19.3
Outpatient Detoxification Programs
(ASAM Level I-D and Level II-D).
19.3.1 Definition. Outpatient detoxification
programs provide services to persons who are experiencing no more than moderate
withdrawal symptoms, and do not have co-morbid medical or psychiatric
conditions that require 24-hour inpatient care. Services include a
biopsychosocial evaluation, medical observation, monitoring, and follow-up
referral. Services may be conducted in a freestanding or other appropriately
licensed healthcare or addiction treatment facility. Clients experiencing, or
at risk of experiencing acute withdrawal syndrome are not appropriate
candidates for outpatient detoxification.
19.3.2 Services provided. The outpatient
detoxification program shall provide immediate medical evaluation and continued
medical management in an ambulatory setting, including:
19.3.2.1 daily medical monitoring and
management of acute withdrawal symptoms;
19.3.2.2 biopsychosocial assessment,
including assessment of availability of support for the client in the
community;
19.3.2.3 appropriate
referrals for further mental health or medical consultation;
19.3.2.4 24-hour access to medical
care;
19.3.2.5 assessment of
clients' medical and behavioral symptoms on at least a daily basis;
19.3.2.6 planning for and referral to further
treatment.
19.3.3 Staff.
19.3.3.1 Outpatient detoxification programs
will be staffed by physicians or physician extenders who are available 24 hours
a day by telephone.
19.3.3.2 A
registered nurse or other licensed and credentialed nurse shall be available to
conduct a nursing assessment on admission.
19.3.3.3 An interdisciplinary team of
appropriately trained clinicians shall be available to assess and treat the
client with a substance-related disorder, or an addicted client with a
co-occurring acute biomedical, emotional, or behavioral disorder.
19.3.4 Client records.
19.3.4.1 Elements of the assessment and
treatment plan will include, but not be limited to:
19.3.4.1.1 An addiction-focused history,
obtained as part of the initial assessment and reviewed by a physician during
the admission process;
19.3.4.1.2 A
record of a physical examination by a physician or physician extender,
performed within 24 hours of admission, accompanied by appropriate laboratory
and toxicology tests OR the evaluation of the records of a physical examination
administered within the preceding 7 calendar days prior to admission, by a
physician or physician extender;
19.3.4.1.3 Sufficient biopsychosocial
screening assessments to determine the level of care in which the client should
be placed and for the individualized care plan to address treatment
priorities;
19.3.4.1.4 An
individualized treatment plan, including problem identification, treatment
goals, measurable treatment objectives, and activities designed to meet those
objectives.
19.3.4.2
Other documentation will include:
19.3.4.2.1
Progress notes that clearly reflect implementation of the treatment plan and
the client's response to treatment, as well as subsequent amendments to the
plan;
19.3.4.2.2 Detoxification
rating scale tables and flow sheets, as needed;
19.3.4.2.3 Physician services, documented in
the client record as they occur;
19.3.4.2.4 Notes of client progress entered
by nurses at least once daily;
19.3.4.2.5 Notes of client progress entered
by clinical staff at least once daily;
19.3.4.2.6 A record of discharge/transfer
planning, beginning at admission.
19.4
Shelter Services.
19.4.1 Definition. Shelter is a service which
provides food, lodging and clothing for abusers of alcohol and other drugs,
with the purpose of protecting and maintaining life and providing motivation
for alcohol and drug treatment.
19.4.2 Services Provided. Services provided
will include but not necessarily be limited to:
19.4.2.1 food and beverages when the shelter
is in operation;
19.4.2.2 clean
clothing, with laundry facilities available on the premises;
19.4.2.3 clean bedding;
19.4.2.4 shower or bathing
facilities;
19.4.2.5 supplies for
personal hygiene;
19.4.2.6 referral
to detoxification or other suitable treatment, as needed;
19.4.2.7 arrangements for needed health care
services through written agreements with detoxification centers, hospitals, and
other emergency care facilities;
19.4.2.8 encouragement for participation in
self-help groups;
19.4.2.9
transportation between the program and emergency healthcare
facilities.
19.4.3
Staff. In addition to the General Requirements listed above, staff will receive
training:
19.4.3.1 to carry out emergency
procedures, including CPR and first aid, and become certified in these
procedures;
19.4.3.2 to recognize
signs that could indicate the physical deterioration of a client;
19.4.3.3 to recognize suicidal indicators and
to notify clinical staff if indicators are present;
19.4.3.4 to motivate the client to accept
detoxification or other suitable treatment;
19.4.3.5 in referral procedures;
19.4.3.6 to maintain records of shelter
utilization;
19.4.3.7 to identify
potentially harmful items and to supervise their use.
19.5
Residential Treatment
Programs (ASAM Level III).
19.5.1
Definition. Residential treatment programs provide services in a full (24
hours) residential setting. The program shall provide a scheduled treatment
regimen which consists of diagnostic, educational, and counseling services; and
shall refer clients to support services as needed. Clients are routinely
discharged to various levels of follow-up services. There are three categories
of residential care:
19.5.2
Category I. Category I residential treatment programs maintain a
basic focus on early recovery skills, including the negative impact of chemical
dependency, tools for developing support, and relapse prevention skills.
Examples of Category I programs are extended shelters and residential
rehabilitation programs. Category I programs are characterized by the following
criteria:
19.5.2.1 The term of residency shall
not exceed 45 days without documented assessment of client's need for the
extension and a treatment plan indicating goals congruent with the definition
and purpose of this component.
19.5.2.2 Individual and group counseling at a
minimum of 14 hours per week or 2 hours per day for each client. The qualified
staff shall teach attitudes, skills and habits conducive to good health and the
maintenance of a substance free life style. The treatment mode may vary with
the member's needs and may be in the form of individual, group or family
counseling at a minimum of fourteen (14) hours per week.
19.5.2.3 Daily didactic/educational
presentations.
19.5.2.4 Programs
shall have staff coverage 24 hours a day, including weekend coverage. The
program shall maintain a medical staffing pattern that enables it to meet the
physical care requirements delineated above. Physician back-up and on-call
staff shall be provided to deal with medical emergencies. The program shall not
subcontract any of its obligations and rights pertaining to medical services
described in this section. For the purposes of this section, physician
consultant services are not considered subcontracting.
19.5.3
Category II. Category II
programs provide a structured residential milieu, to help clients transition
from a substance abusing lifestyle to a solid recovery environment. Clients may
initially receive a treatment focus similar to that of Category I programs, but
will transition to a treatment focus that addresses the cultural, social,
educational, and vocational needs of the client. An example of a Category II
program is a halfway house. Category II programs are characterized by the
following criteria:
19.5.3.1 length of
treatment: up to 180 days duration
19.5.3.2 group/individual/family treatment
sessions appropriate to the phase of treatment
19.5.3.3 living skills training according to
the phase of treatment
19.5.3.4
vocational assessment and preparation
19.5.3.5 supervised housekeeping
responsibilities
19.5.4
Category III. Category III programs provide a long-term supportive
and structured environment for chemically dependent clients with extensive
substance abuse debilitation. These programs provide a supervised living
experience within the program. Qualified staff shall teach attitudes, skills
and habits conducive to facilitating the member's transition back to the
community. The treatment mode may vary with the member's needs and may be in
the form of individual, group or family counseling. Outcome goals may range
from custodial care to further treatment services and recovery. Examples of
Category III programs are adolescent long-term rehabilitation or an extended
care program. Category III programs are characterized by the following
criteria:
19.5.4.1 length of treatment: over
180 days duration
19.5.4.2
group/individual/family treatment sessions appropriate to the phase of
treatment
19.5.4.3 living skills
training according to the phase of treatment
19.5.4.4 vocational assessment and
preparation
19.5.4.5 supervised
housekeeping responsibilities
19.5.4.6 transportation shall be available 24
hours a day. A written agreement shall provide for transportation between the
program and emergency care facilities.
19.5.4.7 The program shall have a written
agreement with an ambulance service to assure twenty-four (24) hour access to
transportation to emergency medical care facilities for clients requiring such
transport. Physician back-up and on-call staff shall be provided to deal with
medical emergencies.
19.5.4.8 A
program shall not subcontract any of its obligations and rights pertaining to
medical services described in these regulations with the exception of physician
consultant services.
19.5.4.9
Extended care services shall provide a scheduled therapeutic plan consisting of
treatment services designed to enable the member to sustain a substance free
life style within a supportive environment.
19.5.5 Services provided. The services shall
depend upon the treatment needs of the individual clients. Services provided
either on site or through referral shall include but not be limited to:
19.5.5.1 Evaluation of the client's medical
and psycho-social needs;
19.5.5.2 A
medical examination by the program's physician within 5 days of admission
unless the physician has approved a prior examination conducted within the last
30 days;
19.5.5.3 Opportunities for
learning basic living skills, such as personal hygiene skills, knowledge of
proper diet and meal preparation, constructive use of leisure time, money
management, and interpersonal relationship skills;
19.5.5.4 Clinical services, including
individual and group counseling;
19.5.5.5 Provisions for family
involvement;
19.5.5.6 Educational
services, vocational placement and training, and recreational opportunities as
appropriate to the client group to be served;
19.5.5.7 Encouragement for participation in
self-help groups. The program shall make agreements with community resources to
provide client services through referrals when the program is unable to provide
them.
19.6
Intensive Outpatient Programs (iop) (ASAM Level II.1).
19.6.1 Definition. Intensive Outpatient
Programs provide an intensive and structured program of alcohol and other drug
assessment and group treatment services in a setting which does not include an
overnight stay. These programs include a structured sequence of multi-hour
clinical and educational sessions scheduled for a minimum of six (6) and
maximum of twenty (20) hours per week per client. Any exceptions to these time
frames must be approved in advance by OSA.
19.6.2 Services Provided.
19.6.2.1 procedures to determine the client's
medical needs. The program will determine the necessity for medical examination
and further consultation. The medical assessment will be part of the client
record;
19.6.2.2 biopsychosocial
assessment, as outlined in Section 15.7;
19.6.2.3 clinical services, to include daily
didactic and counseling groups;
19.6.2.4 educational chemical dependency
groups;
19.6.2.5 involvement of
affected others;
19.6.2.6 planning
for and referral to further treatment, as needed.
19.7
Outpatient Care (ASAM
Level I).
19.7.1 Definition. Outpatient
Care provides assessment and counseling services to chemically dependent
clients and affected others.
19.7.2
Services provided.
19.7.2.1 services offered
according to client need on a scheduled or emergency basis;
19.7.2.2 individual, group, and family
counseling;
19.7.2.3 procedures to
determine the client's medical needs. The program will determine the necessity
for medical examination and further consultation. The medical assessment will
be part of the client record;
19.7.2.4 biopsychosocial assessment, as
outlined in Section 15.6. The program will make appropriate referrals for
further mental health consultation;
19.7.2.5 services to the client, through
referral, in the area of educational enrichment, vocational placement and
training, legal services, and money management, as dictated by client
needs;
19.7.2.6 planning for and
referral to further treatment;
19.7.2.7 education about chemical
abuse.
19.8
Opioid Treatment Program (OTP)
(Opioid Supervised Withdrawal and Maintenance Treatment Module).
19.8.1
Opioid Treatment. Opioid supervised withdrawal and maintenance are
adjunctive treatments for individuals with a current serious physiological
opiate addiction. A client must have an addiction of at least one year duration
in order to qualify for maintenance treatment. Opioid maintenance and treatment
involves the administration of specific opioid agonists under the supervision
of the program Medical Director.
19.8.2
Federal and State
Authority. The administration of opioid agonists will require compliance
with a variety of Federal and Maine State laws, and will also involve oversight
by Federal and State agencies to monitor compliance with these laws and
regulations.
19.8.2.1 Compliance. OTP
compliance with federal and state laws shall be subject to the review and
independent verification of the Licensing Authority.
19.8.2.2 OTPs shall demonstrate compliance
with:
19.8.2.2.1 Federal Certificate. 42 CFR
Chapter 1, Subchapter A, Part 8, as amended, including but not limited to,
possession of a current, valid certificate from the Substance Abuse and Mental
Health Services Administration within the U.S. Department of Health and Human
Services (SAMHSA), which shall be the demonstration of compliance with Sections
303(g)(1) of the Controlled Substances Act (21 United States Code (USC) Section
823(g)(1)), as amended, to dispense opioid drugs in the treatment of opioid
addiction. This will depend upon the OTP obtaining accreditation from an
accreditation body that has been approved by SAMHSA; and
19.8.2.2.2 Maine Criminal Code and Maine
State Pharmacy Act. Chapter 45 of the Maine Criminal Code (
17-A M.R.S.A.
§1101 et seq.), as amended, and the
Maine State Pharmacy Act (
32 M.R.S.A
§13731(2)) , as
amended, and Sections 2.19 of these rules.
19.8.2.2.3 Diversion Control Plan. As part of
the quality assurance plan required by
42 CFR
§8.12(c)(2), OTPs shall
maintain a current Diversion Control Plan. (See 19.8.3.7).
19.8.2.2.4 USFDA Consent to Treatment Form.
Acquire and maintain documentation that shall include the USFDA Form 2635
"Consent to Treatment with an Approved Narcotic Drug." (See
19.8.3.10.4)
19.8.3
Waivers.
19.8.3.1
Program-size Waiver.
Waivers may be granted by the licensing authority to authorize specific OTP
licensed program sites to exceed the 500-client maximum if the program meets
the following requirements:
19.8.3.1.1 The
physical plant is adequate to accommodate the proposed number of
clients;
19.8.3.1.2 The program has
the ability to hire and retain adequate numbers of qualified staff to meet the
standards in this rule;
19.8.3.1.3
A demonstrated need for increased services that cannot be reasonably met except
by expansion of the program size; and
19.8.3.1.4 Written agreement by the program
to accept the conditions of the waiver as enforceable as rule.
19.8.3.2
Caseload-size
Waiver.
19.8.3.2.1 A temporary,
time-limited, waiver may be granted by the licensing authority to authorize a
specific OTP licensed program site to exceed the 50-client maximum for any
counselor employed by the OTP on a full-time basis when the OTP is actively
recruiting replacement staff. (See 19.8.8.6.3)
19.8.3.2.2 Unless the licensing authority
grants a waiver, caseloads shall not exceed 35 clients for counselors employed
by the OTP on a full-time basis who have not completed 2000 hours of substance
abuse practice under clinical supervision. (See 19.8.8.6.4)
19.8.4
General
Requirements. Opioid Treatment Programs (OTPs) shall meet the following
requirements, in addition to the requirements of Sections
2 through
19 of these rules:
19.8.4.1 An OTP may exist in a number of
settings, including, but not limited to, intensive outpatient, residential, and
hospital settings. Types of treatment may include medical maintenance,
medically supervised withdrawal, and detoxification, either with our without
various levels of medical, psychosocial, and other types of care.
19.8.4.2 OTPs shall be open seven days
weekly, including all holidays;
19.8.4.3 Program size. OTPs shall limit their
program size to no more than 500 clients at each licensed/certified site., unless a waiver is granted. (See
19.8.3.1)
19.8.4.4 Prior to
admitting a client, OTPs shall submit client data to the Office of Substance
Abuse (OSA) according to specifications as shall be determined by OSA. The
specifications shall include content, form, format, frequency, and due date for
submission. This data will be made available only for research and program
evaluation functions.
19.8.4.5
Prior to admission to an OTP, the OTP shall confirm using OSA's data collection
system that the client is not currently enrolled in another OTP. In the event
that the data collection system is inoperable or unavailable, the OTP shall
check with all other OTPs within three calendar days of admission to the OTP.
19.8.4.5.1 The OTP shall obtain from the
client all releases of information necessary to conduct this
confirmation.
19.8.4.5.2
Documentation that such a confirmation has been made shall be noted in the
client record.
19.8.4.6
Diversion Control Plan. As part of the quality assurance plan required by
42 CFR
§8.12(c)(2), OTPs shall
maintain a current Diversion Control Plan that contains specific measures to
reduce the possibility of diversion of controlled substances from legitimate
treatment use, and that assigns specific responsibility to the medical director
and the program manager for carrying out the diversion control measures and
functions described in the Diversion Control Plan.
19.8.4.7 Emergency Administration of
Medications Plan. There shall be a current plan for emergency administration of
medications in case the program is required to close temporarily on an
emergency basis, including how clients are to be informed of these emergency
arrangements.
19.8.4.8 Disaster
Plan. There shall be a current disaster plan, that shall address at least the
following:
19.8.4.8.1 Natural disasters and
man-made disasters, or other serious events;
19.8.4.8.2 Disasters that may occur when the
OTP is open and when it is closed;
19.8.4.8.3 Security of medication and
records;
19.8.4.8.4 Safety of
clients and staff, including an evacuation plan; and
19.8.4.8.5 Any other situation that is unique
to the OTP.
19.8.4.9
Informed Consent. There shall be current procedures to ensure that the informed
written consent to treatment of clients is received. Specifically, the OTP
shall:
19.8.4.9.1 Ensure that admission is
voluntary;
19.8.4.9.2 Ensure that
all relevant facts concerning the use of the opioid drug are clearly and
adequately explained to the client. This will include, but not necessarily be
limited to, the risks and benefits of treatment, other treatment options, and
the fact that opioid agonist drugs cause dependence and dosage
tolerance;
19.8.4.9.3 Ensure that
the reasons for and ramifications of administrative supervised withdrawal are
explained to the client; and
19.8.4.9.4 Acquire and maintain documentation
that shall include the Client Rights and Responsibility Disclosure Forms signed
by the client, and USFDA Form 2635 "Consent to Treatment with an Approved
Narcotic Drug."
19.8.4.10 Transfers. OTPs shall develop and
follow policies and procedures to effect orderly transfers of clients between
substance abuse programs. Records shall be provided promptly to the receiving
substance abuse program. Records shall be complete at the time of transfer.
Reports to OSA data collection system shall be completed at the time of
transfer.
19.8.4.11 Administrative
Withdrawal. OTPs shall develop and follow policies and procedures, consistent
with best practices and applicable law and rule, governing administrative
withdrawal. Administrative withdrawal may not be used by OTPs to discipline
clients for minor infractions of program policy. Clients who are involuntarily
withdrawn from treatment for administrative reasons shall be treated with
compassion, respect and dignity. Dosage withdrawal schedules shall be developed
and documented for each individual client being administratively withdrawn,
considering the maintenance dosage, individual tolerance of dosage reduction,
and psychiatric and medical comorbidities.
19.8.4.12 Critical Incident Reporting. OTPs
shall adhere to critical incident reporting procedures required by OSA. (See
section 5.2)
19.8.4.13 OTPs shall
invite the public, municipal officials including but not limited to elected
officials, public health and public safety officials to an annual meeting with
clinic management and Office of Substance Abuse staff to discuss the clinic's
impact on the municipality.
19.8.5
Required Services. OTPs
shall provide adequate medical, counseling, vocational, educational and other
assessment and treatment services that are fully and reasonably available to
clients.
19.8.5.1 The services may be
provided by the OTP at the OTP primary site or through a contracted staff
agreement. All assessments, evaluations and interventions shall be documented
in the client record.
19.8.5.2
Medical examinations. Initial medical examinations are required at
the time of admission to the OTP. The examination may be conducted by the OTP
physician, a primary care physician, or a physician extender as permitted by
rule and law.
19.8.5.2.1 The examination
shall include serology and other relevant tests. The examination shall be
completed within fourteen (14) days following admission, including the review
of results of serology and other tests.
19.8.5.2.2 Testing shall be conducted for
tuberculosis, syphilis, and liver function. Further testing for Hepatitis B and
C shall be available if indicated.
19.8.5.2.3 Voluntary screening for Human
Immunodeficiency Virus (HIV) and other sexually transmitted infections shall be
available. When appropriate, referral to other providers of these services
shall be made and documented in the client record.
19.8.5.2.4 Clients shall be provided with all
baseline testing recommended in pharmaceutical inserts of medications being
considered for use.
19.8.5.2.5 All
female clients of childbearing potential shall be tested for pregnancy upon
admission to the OTP and as needed during the course of treatment. Pregnant
clients shall be referred to prenatal care.
19.8.5.2.6 Results of examinations completed
within the prior 12 months may be used for clients readmitted to a program
within 3 months of discharge.
19.8.5.2.7 Clients transferring from another
program shall complete all screening and admission procedures except in
documented emergencies.
19.8.5.3
Initial Assessments.
Initial assessments shall include a detailed bio-psycho-social evaluation,
which shall provide supportive evidence that opioid agonist treatment is the
medically appropriate treatment for the client. The evaluation shall include
documentation of any previous treatment experiences.
19.8.5.4
Rehabilitation
Counseling. Unless an exception is granted under section 19.8.1 1.3,
rehabilitation counseling services shall be provided by the OTP staff and shall
be consistent with the client's treatment plans. The client record shall include documentation of
the provision of counseling and the results of counseling. This counseling
shall be in addition to the face-to-face evaluation done at the time of
dosing.
19.8.5.5
Phase 1 -
Initiation or Induction
19.8.5.5.1
Duration- Minimum 45 days
19.8.5.5.2 Counseling Requirement - Total 4
(four) hours of counseling that could include individual counseling, group
counseling, psycho-educational, psychodynamic or support group
sessions.
19.8.5.5.3 Individual
counseling may be provided in either 15 or 30 minute sessions.
19.8.5.5.4 Required Goals for Phase 1
Completion
19.8.5.5.4.1 initially prescribing
a medication dosage that minimizes sedation and other undesirable side
effects
19.8.5.5.4.2 assessing the
safety and adequacy of each dose after administration
19.8.5.5.4.3 rapidly but safely increasing
dosage to suppress withdrawal symptoms and cravings and discourage patients
from self-medicating with illicit drugs or alcohol or by abusing prescription
medications
19.8.5.6
Phase 2 - Acute
Treatment
19.8.5.6.1 Duration- Minimum
60 days
19.8.5.6.2 Counseling
Requirement - Total 6 (six) hours of counseling that could include individual
counseling, group counseling, psycho-educational, psychodynamic or support
group sessions.
19.8.5.6.3
Individual counseling may be provided in either 15 or 30 minute
sessions.
19.8.5.6.4 Required Goals
for Phase 2 Completion
19.8.5.6.4.1
elimination of symptoms of withdrawal, discomfort, or craving for
opioids
19.8.5.6.4.2 providing or
referring patients for services to lessen the intensity of co-occurring
disorders and medical, social, legal, family, and other problems associated
with opioid addiction
19.8.5.6.4.3
helping patients identify high-risk situations for drug and alcohol use and
develop alternative strategies for coping with cravings or compulsions to abuse
substances.
19.8.5.6.4.4
satisfaction of basic needs for food, shelter, and safety.
19.8.5.7
Phase 3 -
Rehabilitation
19.8.5.7.1 Duration -
Minimum 90 days
19.8.5.7.2
Counseling Requirement - Total 6 (six) hours of counseling that could include
individual counseling, group counseling, psycho-educational, psychodynamic or
support group sessions.
19.8.5.7.3
Individual counseling may be provided in either 15 or 30-minute
sessions.
19.8.5.7.4 Required Goals
for Phase 3 Completion
19.8.5.7.4.1 abstinence
from illicit opioids and from abuse of opioids normally obtained by
prescription, as evidenced by drug tests
19.8.5.7.4.2 amelioration of signs of opioid
withdrawal
19.8.5.7.4.3 reduction
in physical drug craving
19.8.5.7.4.4 elimination of illicit-opioid
use and reduction in other substance use, including abuse of prescription drugs
and alcohol
19.8.5.7.4.5 completion
of medical and mental health assessment
19.8.5.7.4.6 development of a treatment plan
to address psychosocial issues such as education, vocational goals, and
involvement with criminal justice and child welfare or other social service
agencies as needed
19.8.5.8
Phase 4 - Supportive
Care
19.8.5.8.1 Duration-ongoing 90 day
periods
19.8.5.8.2 Counseling
Requirement - Total 3 (three) hours of counseling that could include individual
counseling, group counseling, psycho-educational, psychodynamic or support
group sessions.
19.8.5.8.3
Individual counseling may be provided in either 15 or 30 minute
sessions.
19.8.5.8.4 Required Goals
for Phase 4 Completion
19.8.5.8.4.1 engagement
with treatment staff in assessment of medical, mental health, and psychosocial
issues as evidenced by kept appointments and clinic attendance
19.8.5.8.4.2 stable living conditions in an
environment free of substance use
19.8.5.8.4.3 stable and legal source of
income
19.8.5.8.4.4 involvement in
productive activities (e.g., employment, school, volunteer work)
19.8.5.8.4.5 no criminal or legal
involvement
19.8.5.9
Phase 5 - Medical
Maintenance
19.8.5.9.1 Duration -
ongoing 90 day periods
19.8.5.9.2
Counseling Requirement - Total 1 (one) hour and will include time spent to
review the treatment plan and could include individual counseling, group
counseling, psycho-educational, psychodynamic or support group
sessions.
19.8.5.9.3 Individual
counseling may be provided in either 15 or 30 minute sessions.
19.8.5.9.4 Required Goals for Phase 5
Completion
19.8.5.9.4.1 two (2) years of
continuous treatment
19.8.5.9.4.2
abstinence from illicit drugs and from abuse of prescription drugs (as
evidenced by drug tests) for at least 2 years for a full 30-day maintenance
dosage.
19.8.5.9.4.3 no alcohol use
problem
19.8.5.9.4.4 stable living
conditions in an environment free of substance use
19.8.5.9.4.5 stable and legal source of
income
19.8.5.9.4.6 involvement in
productive activities (e.g. employment, school, volunteer work)
19.8.5.9.4.7 no criminal or legal involvement
for at least 3 years and no current parole o probation status
19.8.5.9.4.8 adequate social support system
and absence of significant un-stabilized co-occurring disorders
19.8.5.10
Education on HIV. Education on HIV and Hepatitis shall be provided
to all clients. Additional education on other infectious diseases shall be
provided by the OTP to clients, as dictated by client need. Education shall be
documented in the client record.
19.8.6
Treatment Plans.
Treatment plans shall be developed to describe the most appropriate combination
of services and treatment.
19.8.6.1 The
initial treatment plan shall be in writing and completed within 7 calendar days
of admission. It shall be developed and signed by the client, the primary
counselor and the medical director.
19.8.6.2 The treatment plan shall include
both short and long term goals, the services and/or steps necessary to achieve
the goals, the frequency with which the services are provided, and the staff
position or entity assuming responsibility for the provision of the
services.
19.8.6.3 Updates to the
plan shall be in writing and shall reflect the client's personal history,
current needs, and degree of achievement of short and long term
goals.
19.8.6.4 Updates shall be
completed no less frequently than every 90 days. They shall be reviewed and
revised if needed whenever there is a significant change in the client's
status. They shall be signed by the primary counselor and client.
19.8.6.5 Treatment plans shall include the
rationale for the use of the dosage plan. This shall be documented by a
physician or physician extender. Initial doses of methadone shall not exceed 30
milligrams unless the physician documents the need for a higher dose.
19.8.6.6 Results of drug tests shall be
documented in the client record and there shall be a clear indication in the
client record that the results of drug testing have been reviewed and
considered as part of the treatment planning process and decisions for
take-home dosing.
19.8.6.7 The
medical director shall review and sign treatment plans on an annual
basis.
19.8.7
Requirements for Maintenance Programs. All maintenance treatment
programs shall operate as follows:
19.8.7.1
Population to be served.
19.8.7.1.1 Addiction
status. Clients shall be currently addicted to an opioid drug and shall have
become addicted at least one (1) year before admission for treatment.
19.8.7.1.2 Age. Clients will be 18 years of
age or older, unless approved by the Office of Substance Abuse, and the
following requirements are met:
19.8.7.1.2.1
Clients under the age of 18 may not be admitted unless a parent, legal
guardian, or responsible adult approved by OSA consents in writing to such
treatment; and
19.8.7.1.2.2 Clients
under the age of 18 are required to have had two documented unsuccessful
attempts at short-term supervised withdrawal or drug-free treatment within a 12
month period.
19.8.7.1.3
Priority Clients. Pregnant clients and those who are HIV positive will be
considered priority clients. Pregnant clients, regardless of age, may be placed
on a regimen of opioid agonists, provided that the medical director certifies
to the pregnancy, and documents that the treatment is medically
justified.
19.8.7.1.4 If clinically
appropriate, the OTP physician may-dispense with the requirement of a 1 year
history of addiction for clients released from penal institutions (if within 6
months after release), for pregnant clients (if the pregnancy has been
certified) and for previously treated clients (up to 2 years after
discharge).
19.8.7.2
Drug Testing Services. The OTP shall develop and follow policies and
procedures, consistent with best practices and applicable law and rule,
governing drug testing practices. The policy and procedure shall be approved by
OSA. At minimum, drug testing policies shall include the following:
19.8.7.2.1 Prompt Testing. All drug testing
samples shall be tested promptly. Testing facilities shall be qualified to
conduct testing.
19.8.7.2.2 Drug
Testing at Admission. All clients will have a drug test at admission. A
positive test is not a requirement for admission to the OTP.
19.8.7.2.3 Required Screens. All required
drug tests shall include screening for opiates, methadone, cocaine,
benzodiazepines and other substances of abuse prevalent in the community.
19.8.7.2.3.1 Additionally, the drug test at
admission shall include screening for cannabis.
19.8.7.2.3.2 Random drug samples shall be
collected no less frequently than every 30 days unless the individual treatment
plan indicates more collections are necessary. If the admission drug test was
positive for cannabis, periodic screens for cannabis shall be conducted and
documented.
19.8.7.2.3.3 Drug tests
in addition to those required by this rule need to include only those screens
specific to the individual client's treatment needs.
19.8.7.2.4 Use of Results. Results of drug
testing shall be used as a factor in making treatment decisions. Results of
drug testing shall not be used in a punitive manner. There shall be a clear
indication in the client record that the results of drug testing have been
reviewed and considered as part of the treatment planning process and decisions
for take-home dosing.
19.8.7.2.5
Sample Integrity. Adequate and appropriate steps shall be taken to prevent
falsification or substitution in sample collection.
19.8.7.2.5.1 The routine use of observation
techniques such as cameras and windows is prohibited.
19.8.7.2.5.2 The use of observation shall be
clinically substantiated and gender appropriate.
19.8.8
Staff
Requirements.
19.8.8.1 The Medical
Director shall be a physician licensed to practice in the State of Maine, and
in addition shall be certified b the American Society of Addiction Medicine
(ASAM) or otherwise qualified through education, experience and training in
addictions.
19.8.8.1.1 The medical director
shall assume responsibility for administering all medical services performed by
the OTP, either by performing them directly or by delegating specific
responsibility to authorized program physicians and healthcare professionals
functioning under the medical director's direct supervision. The medical
director shall meet the requirements described at Section
10
.0 of these rules.
19.8.8.1.2 The medical director shall review
all treatment plans at least once annually and indicate written
approval.
19.8.8.1.3 The medical
director shall review and approve in writing all OTP policies.
19.8.8.1.4 The OTP shall notify the Office of
Substance Abuse of the resignation or replacement of a Medical Director within
five days of such resignation or replacement.
19.8.8.2 Physician extenders as defined in
Section 1.51 may be utilized at an OTP under the following conditions:
19.8.8.2.1 Physicians Assistants (PAs) may
practice as described at 02-373 Code of Maine Rules (CMR) Chapter 2, as
amended, under the supervision of the Medical Director.
19.8.8.2.2 Nurse Practitioners (CNPs) may
practice as described at 02-373 CMR Chapter 3, as amended, and 02-380 CMR
Chapter 8, as amended, under the supervision of the Medical Director.
19.8.8.3 The Nursing Supervisor
will be a Registered Professional Nurse licensed according to Maine law and who
will have education, experience and training in the treatment of substance
abuse or mental health or both. The nursing staff may include Licensed
Practical Nurses licensed according to Maine law.
19.8.8.4 The Pharmacist will be licensed to
engage in the practice of Pharmacy in the State of Maine.
19.8.8.5 There shall be a Clinical Supervisor
who meets the requirements of Section
11. 0 of these rules.
19.8.8.6 OTPs shall employ an adequate number
of counselors, qualified pursuant to 32 M.R.S.A. Chapter 81, as amended.
19.8.8.6.1 Caseloads for individual
counselors shall be comprised of clients in varying stages of
treatment.
19.8.8.6.2 Caseloads
shall be prorated for counselors employed by the OTP on a part time
basis.
19.8.8.6.3 Caseloads shall
not exceed 50 clients for any counselor employed by the OTP on a full time
basis, unless a waiver is granted. (See Section 19.8.3.2.1).
19.8.8.6.4
19.8.6.6.4Unless the licensing authority grants a
waiver, caseloads shall not exceed 35 clients for counselors employed by the
OTP on a full time basis who have not completed 2000 hours of substance abuse
practice under clinical supervision. (See Section19.8.3.2.2)
19.8.8.7 Training. In addition to
the training requirements of Section 13.5 of these rules, staff will receive:
19.8.8.7.1 An intensive program of training
specific to opioids and opioid agonist issues. The training plan will be
developed by the OTP and staff will have updates annually;
19.8.8.7.2 Training on the subject of HIV
infection and treatment of HIV infected clients; and
19.8.8.7.3 Training on the subject of
Hepatitis B and C and treatment and prevention of Hepatitis.
19.8.8.8 Background Checks.
Background checks, including but not necessarily limited to conviction of
offenses related to the possession, use, sale or distribution of controlled
substances shall be conducted.
19.8.8.8.1 The
expense of such background checks shall be borne by the OTP.
19.8.8.8.2 Persons who have been convicted of
any felony, or an offense related to the possession, use, sale, or distribution
of controlled substances, may be employed by the OTP in a position with access
to a scheduled or prescription drug or controlled substance only if the OTP
documents in the person's personnel file the offense and sanction, the OTP's
assessment of the seriousness of the factual basis for the offense, and the
agency's rationale for hiring and/or retaining the person.
19.8.8.8.3 OTPs shall not engage in any
capacity any person if there exists a reasonable articulable suspicion of
current use of illicit substances or criminal activity related to possession,
use, sale or distribution of controlled substances.
19.8.9
Medication
Administration at the OTP. OTPs shall develop and follow policies and
procedures that are adequate to ensure that treatment medication used by the
program is administered and dispensed in accordance with approved product
labeling and that the following dosage form and initial dosing requirements are
met:
19.8.9.1 The OTP shall utilize an
effective procedure to ensure that client identity and the correct dose and
medication are being verified prior to medication administration. Ingestion and
swallowing shall be observed by the staff person who administered the
medication, who shall document the administration of the medication in the
record.
19.8.9.2 At the time of
dosing there shall be a face to face clinical evaluation by qualified staff
that may be short in duration. If the evaluation indicates the need for further
evaluation or intervention, the evaluation or intervention shall be documented
in the client record.
19.8.9.3
Medication may be withheld when the OTP physician or physician extender
determines that administration of the medication would not be medically or
clinically appropriate. The withholding of medication shall be substantiated in
the record and signed by the authorizing practitioner.
19.8.9.4 When clients transfer from one OTP
to another, medication doses may be communicated from medical personnel at the
discharging program to medical personnel at the admitting program, as may be
permitted by applicable law and rule.
19.8.9.5 OTPs shall develop and follow
policies and procedures regarding courtesy dosing. Policies shall address
situations in which the OTP is requesting courtesy dosing for a client and when
it is providing courtesy dosing. Policies shall be based on best practice
standards. Policies shall address verification of client identify, verification
of dose and medication, documentation of medication administration.
19.8.10
Unsupervised or
Take-Home Use. The OTP shall develop and follow policies and procedures
regarding take-home privileges. The policy shall ensure the following:
19.8.10.1 All decisions regarding take-home
privileges shall be documented in the client record and shall comply with the
requirements cited in 42 CFR Chapter 1, Subchapter A, Part 8.
19.8.10.2 Medication shall be dispensed only
in oral form.
19.8.10.2.1 Methadone shall be
dispensed in liquid form only in single dose containers, or in dry form only in
multiple dose containers.
19.8.10.2.2 Other medications shall be
dispensed according to federal regulations and manufacturer's
recommendation.
19.8.10.3 Clients will not be allowed
take-home privileges during the first ninety (90) continuous days of
treatment.
19.8.10.4 After ninety
(90) continuous days of treatment, clients may be allowed take-home privileges
no greater than the following schedule:
19.8.10.4.1 From the ninety first (91st) to
the one hundred eightieth (180th) continuous days of treatment, one take-home
dose per week is permitted;
19.8.10.4.2 From the one hundred eighty first
(181st) to the two hundred seventieth (270th) continuous days of treatment, two
take-home doses per week are permitted;
19.8.10.4.3 From the two hundred seventy
first (271st) to the three hundred sixtieth (360th) continuous days of
treatment, three take-home doses per week are permitted;
19.8.10.4.4 From the, three hundred sixty first (361st) continuous day
of treatment onward, six take-home doses per week are permitted.
19.8.11
Exception Request and Record of Justification for client exceptions.
OTPs are responsible for providing documentation supporting the clinical
justification for requested exceptions. Requests for exceptions and the
documentation required to demonstrate clinical justification shall be delivered
to OSA in the form and format required by OSA no later than five business days
prior to the day the requested exception is to take effect.
19.8.11.1 Split-dose exception. A federal
exception request must be secured from the U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Administration, and approved by
OSA, before an OTP is authorized to dispense a split-dose to a client. For
purposes of this section, a split-dose is defined as the balance of a dose that
shall be taken by a client off the site of the OTP, after the initial dose is
administered on site. Split-dosing may only be authorized if medically
necessary. Acceptable documentation that the OTP received the federal and state
response to the requested exception must be placed in the client's
file.
19.8.11.2 Home schedule
exception. Exceptions to take-home schedules required by state rules that are
stricter than federal rules must be approved by OSA. When an exception to a
federal requirement is requested, the OTP must secure an exception from the
U.S. Department of Health and Human Services, Substance Abuse and Mental Health
Administration, and have it approved by OSA, before an OTP is authorized to
grant the exception. Acceptable documentation that the OTP received the federal
and state response, as applicable, to the requested exception must placed in
the client's file.
19.8.11.3
Rehabilitation counseling exception. OSA is authorized to grant an exception to
rehabilitation counseling requirements established by state rules that are
stricter than federal rules. An exception must be time-limited and based on a
client's inability to attend the counseling sessions due to illness or injury.
The OTP must secure a written OSA exception for the client before the OTP is
authorized to adjust the hours of rehabilitation counseling required by Phase
1, 2, 3, 4, or 5 of sections 19.8.5.5, 19.8.5.6, 19.8.5.7, 19.8.5.8, and
19.8.5.9. Documentation of the OSA granted exception must be placed in the
client's file. No client will be allowed to advance to a higher phase of
treatment until the minimum rehabilitation counseling and goals for their
current phase of treatment have been completed.
19.8.12
Emergencies. In
emergencies, take-home doses may be provided under the following circumstances:
19.8.12.1 The program has made reasonable,
documented attempts to contact OSA for permission;
19.8.12.2 The nature of the emergency has
been verified by the program and documented in the record;
19.8.12.3 The client has met the minimum
requirements for take-home privileges; and
19.8.12.4 The program director and the
medical director document this decision in the record. Documentation of this
decision shall be submitted to OSA by the program director within one business
day.
19.9
Social Setting Detoxification Programs
(Clinical Managed Residential Detoxification, ASAM Level III.2-D).
19.9.1
Definition: Social Setting Detoxification Programs provide services to persons
who are experiencing withdrawal symptoms that require 24-hour structure and
support but don't require full resources of Medically Managed Intensive
Detoxification or Freestanding Residential Detoxification, recognizing that the
emphasis is more on the counseling program as a treatment agent as opposed to
professional intervention and/or medical detoxification. Services must be
conducted in a licensed health care or addiction treatment facility.
19.9.2 Services provided. Social Setting
Detoxification Programs shall provide immediate medical evaluation, diagnosis
and care, including:
19.9.2.1 Access to
immediate medical monitoring on a 24-hour per day basis;
19.9.2.2 Supervision of clients by properly
trained staff until the client is no longer intoxicated;
19.9.2.3 Referral to other services not
provided by the Social Setting Detoxification Program.
19.9.2.4 A physical examination by a
physician or physician's assistant within 48 hours of admission;
19.9.2.5 Written arrangements for hospital
care for medical services beyond the capability of the program
19.9.2.6 Nutritional services, including
special diets as needed. In addition to the requirements in Sections 17.2.5 -
17.2.5.5 of these regulations, the kitchen shall be capable of providing for
preparation of snacks, soup and sandwiches, decaffeinated coffee, and juices
which shall be available for clients.
19.9.2.7 Individual and group counseling, or
provision of such counseling through other resources;
19.9.2.8 A supportive environment which
offers a controlled group living experience;
19.9.2.9 Opportunities for family involvement
and referral of family to counseling when appropriate;
19.9.2.10 Motivational counseling to seek
further treatment;
19.9.2.11
Planning for and referral to further substance abuse treatment; and
19.9.2.12 Transportation support shall be
available 24 hours a day. A written agreement shall provide for transportation
between the program and emergency health care facilities;
19.9.3 Staff.
19.9.3.1 Social Setting Detoxification
Programs shall be staffed by physicians or physician
extenders who are available 24-hours a day by telephone.
19.9.3.2 A registered nurse or other licensed
and credentialed nurse shall be available to conduct a nursing assessment on
admission. The level of nursing care must be appropriate to the severity of
client need.
19.9.3.3 Appropriately
trained and certified/credentialed staff shall be available to administer
medications in accordance with physician orders.
19.9.3.4 Appropriately credentialed alcohol
and drug counselors shall provide evaluation and treatment services for
clients, and family support as needed.
19.9.3.5 An interdisciplinary team of
appropriately trained clinicians shall be available to assess and treat the
client and to obtain and interpret information regarding the client's needs.
The number and disciplines of team members are appropriate to the range and
severity of the client's problems.
19.9.3.6 Staff involved with clients shall be
highly skilled, specially selected, and trained to recognize impending
alcohol/other drug emergencies, and have the capability to refer clients
evidencing such impending emergencies to an alternative medical emergency
back-up facility.
19.9.3.7 All
personnel providing client care shall have completed, prior to employment, the
standard first aid and cardiopulmonary resuscitation (CPR) certification, or
its equivalents, and shall complete, within six months of their employment, the
advanced first aid class or its equivalent.
19.9.3.8 Clinical supervision shall be
provided to all staff on a weekly basis.
19.9.4 Medication.
19.9.4.1 Nothing in this section shall be
construed as authorizing or permitting any person to do any act outside of
federal or state laws.
19.9.4.2 No
medication should be taken without medical direction. If the client brings
drugs into the program for previously existing disorders:
19.9.4.2.1 The actual medication must be
identified by a physician or a pharmacist, and
19.9.4.2.2 A physician must approve the
prescribed dose, and
19.9.4.2.3
These drugs shall be stored in accordance with Section 17.7 through 17.7.1.9 of
these rules.
19.9.4.3
Clients shall self-administer their medication. Self-administration of
medication is defined as giving the client the opportunity of taking
medications according to prescription so long as the client is determined to be
mentally and physically capable of doing so by the medical director.
19.9.4.4 If the medical director determines
the client needs supervision in the administration of the medication, the
medical director shall so indicate in the medical orders.
19.9.5 Client records shall contain but not
be limited to the following documentation:
19.9.5.1 Notes of client progress shall be
entered by clinical staff at least once daily;
19.9.5.2 Elements of the assessment and
treatment plan including, but not be limited to:
19.9.5.2.1 An addiction-focused history,
obtained as part of the initial assessment and reviewed by a physician during
the admission process;
19.9.5.2.2 A
record of a physical examination by a physician or physician extender,
performed within 48 hours of admission, accompanied by appropriate laboratory
and toxicology tests OR the evaluation of the records of a physical examination
administered within the preceding 7 calendar days prior to admission, by a
physician or physician extender;
19.9.5.2.3 Sufficient biopsychosocial
screening assessments to determine the level of care in which the client should
be placed and for the individualized care plan to address treatment
priorities;
19.9.5.2.4 An
individualized treatment plan, including problem identification, treatment
goals, measurable treatment objectives, and activities designed to meet those
objectives.
19.9.5.3
Other documentation including, but not limited to:
19.9.5.3.1 Progress notes that clearly
reflect implementation of the treatment plan and the client's response to
treatment, as well as subsequent amendments to the plan;
19.9.5.3.2 Detoxification rating scale tables
and flow sheets, as needed;
19.9.5.3.3 Physician services, documented in
the client record as they occur;
19.9.5.3.4 A record of discharge/transfer
planning, beginning at admission.
19.9.6
Program Completion
Criteria.
19.9.6.1 Programs shall
describe in detail the indicators used to determine satisfactory completion of
the detoxification process.
19.9.6.2 Programs shall describe conditions
under which clients will be discharged before successful program
completion.
19.10
Medication Assisted Treatment
(MAT).
19.10.1 MAT is a treatment for
addiction and COD that includes medication (e.g. psychotherapeutic medications,
methadone, buprenorphine, naltrexone, accomprosate, vivitrol). MAT is intended
to help stabilize addiction and COD symptoms
19.10.2 MAT and Opiate Treatment Programs
(OTP). An OTP is a treatment program certified by the federal Substance Abuse
and Mental Health Services Administration (SAMHSA) in conformance with 42 Code
of Federal Regulations (C.F.R.), Part 8, to provide supervised assessment and
MAT for clientswho are opioid addicted.
19.10.3 MAT may be provided in an OTP or an
OTP medication unit (pharmacy, physician's office) or, for buprenorphine and
other medications, a physician's office or other healthcare setting.
19.10.4 Types of MAT. Comprehensive
maintenance, medical maintenance, interim maintenance, detoxification, and
medically supervised withdrawal are types of MAT.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.