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NEW YORK CODES, RULES AND REGULATIONS
TITLE 14. DEPARTMENT OF MENTAL HYGIENE
CHAPTER XXI. OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
PART 818. CHEMICAL DEPENDENCE INPATIENT REHABILITATION SERVICES
Date:
08/31/2009
Document:
ยง 818.4 Post admission procedures
(a) Comprehensive evaluation.
(1) The goal of the comprehensive evaluation shall be to obtain that information necessary to develop an individual treatment plan.
(2) The comprehensive evaluation shall obtain that information necessary to determine whether a diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or another Office approved protocol is indicated.
(3) Each comprehensive evaluation shall be based, in part, on clinical interviews with the patient, and may also include interviews with significant others, if possible and appropriate.
(4) No later than three days after admission, staff shall complete the patient's comprehensive evaluation which shall include a written report of findings and conclusions addressing, at a minimum, the patient's:
(i) chemical use, abuse and dependence history;
(ii) history of previous attempts to abstain from chemicals and previous treatment experiences;
(iii) comprehensive psychosocial history, including, but not limited to, the following:
(A) legal involvements;
(B) HIV and AIDS, tuberculosis, hepatitis or other communicable disease risk assessment;
(C) relationships with, history of the use of chemicals by, and the impact of the use of chemicals on, significant others;
(D) an assessment of the patient's individual, social and educational strengths and weaknesses, including, but not limited to, the patient's literacy level, daily living skills and use of leisure time;
(E) the patient's medical history, mental health history, current status, and the patient's lethality (danger to himself/herself or to others) assessment; and
(F) a specific diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or another Office approved protocol.
(5) The comprehensive evaluation shall include an identification of initial services needed, and schedules of individuals and group counseling to address the needed services until the development of the comprehensive treatment plan. The initial services shall be based on goals the patient identifies for treatment and shall include chemical use and any other priority issues identified in the admission assessment.
(6) The comprehensive evaluation shall bear the names of the staff members who participated in evaluating the individual and must be signed by the qualified health professional responsible for the evaluation.
(b) Medical history. (1) For those patients who do not have available a medical history and no physical examination has been performed within 12 months, within three days after admission the patient's medical history shall be recorded and placed in the patient's case record and the patient shall receive a physical examination by a physician, physician's assistant, or a nurse practitioner. The physical examination may include but shall not be limited to the investigation of, and if appropriate, screenings for infectious diseases; pulmonary, cardiac or liver abnormalities; and physical and/or mental limitations or disabilities which may require special services or attention during treatment. The physical examination shall also include the following laboratory tests:
(a) complete blood count and differential;
(b) routine and microscopic urinalysis;
(c) if medically or clinically indicated, urine screening for drugs;
(d) intradermal PPD, given and interpreted by the medical staff unless the patient is known to be PPD positive;
(e) or any other tests the examining physician or other medical staff member deems to be necessary, including, but not limited to, an EKG, a chest X-ray, or a pregnancy test.
(2) If the patient has a medical history available and has had a physical examination performed within 12 months prior to admission, or if the patient is being admitted directly to the inpatient service from another chemical dependence service authorized by the Office, the existing medical history and physical examination documentation may be used to comply with the requirements of this Part, provided that such documentation has been reviewed and determined to be current and accurate.
(3) Patient records shall include a summary of the results of the physical examination and shall also demonstrate that appropriate medical care is recommended to any patient whose health status indicates the need for such care.
(c) After the comprehensive evaluation is completed, a patient shall be retained in such treatment only if the patient:
(1) has a diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or other Office approved protocol;
(2) continues to meet the admission criteria in this Part;
(3) is free of serious communicable diseases that can be transmitted through ordinary contact with other patients;
(4) has no medical or surgical condition or mental disability requiring acute care in a general or psychiatric hospital;
(5) is not in need of medically managed detoxification; and
(6) can benefit from continued treatment in an inpatient service.
(d) If the comprehensive evaluation indicates that the individual needs services beyond the capacity of the inpatient service to provide either alone or in conjunction with another program, referral to appropriate services shall be made. Identification of such referrals and the results of those referrals to identified program(s) shall be documented in the patient record.
(e) If a patient is referred directly to the inpatient service from another service certified by the Office, or is readmitted to the same service within sixty days of discharge, the existing level of care determination and comprehensive evaluation may be used, provided that documentation is maintained demonstrating a review and update.
(f) Treatment plan. A comprehensive written individual treatment plan ("the treatment plan") shall be developed and implemented within seven days after admission to meet the identified needs of the patient in the major functional areas of addiction, physical health and mental health. In addition, the treatment plan shall meet identified needs in other functional areas (i.e. social, emotional, familial, educational, vocational, legal) which are deemed clinically appropriate to address during the patient's stay at the inpatient service. The treatment plan shall take into account cultural, linguistic, and social factors as well as the particular characteristics, conditions and circumstances of patient.
(g) The treatment plan shall take into account cultural and social factors as well as the particular characteristics, conditions and circumstances of the patient. For patients transferring directly from one chemical dependence service to another, an updated treatment plan shall be acceptable.
(h) The patient shall be included and actively participate in the treatment planning process.
(i) The treatment plan shall:
(1) be developed in collaboration with the patient as evidenced by the patient's signature thereon;
(2) be based on the admitting evaluations specified above and any additional evaluation(s) determined to be required;
(3) specify short term goals which can be achieved while the patient is in the service;
(4) prescribe an integrated service of therapies, activities and interventions designed to meet goals;
(5) specify schedules for the provision of all services prescribed;
(6) identify a single member of the clinical staff responsible for coordinating and managing the patient's treatment ("the responsible clinical staff member");
(7) include the diagnosis for which the patient is being treated;
(8) be reviewed, signed and dated by the responsible clinical staff member and reviewed and approved by the multidisciplinary team, as documented by their dated signatures; and
(9) be reviewed, signed and dated by the physician within ten days of admission.
(j) Where a service is to be provided by any other service or facility off site, the treatment plan must contain a description of the nature of the service, a record that referral for such service has been made, and the results of the referral.
(k) Treatment according to the treatment plan. The responsible clinical staff member shall ensure that the treatment plan is included in the patient record and that all treatment is provided in accordance with the individual treatment plan.
(l) If, during the course of treatment, revisions to the treatment plan are determined to be clinically necessary, the treatment plan shall be revised accordingly by the responsible clinical staff member.
(m) The case of any patient who is not responding to treatment, is not meeting goals defined in the comprehensive treatment plan, or is disruptive to the service must be discussed at a case conference by the multidisciplinary team, and the treatment plan revised accordingly.
(n) Documentation of treatment. A progress note shall be written, signed and dated by the responsible clinical staff member or another clinical staff member familiar with the patient's care no less often than once per week. This progress note shall provide a chronology of the patient's progress related to the initial services provided or the goals established in the treatment plan and be sufficient to delineate the course and results of treatment/services. The progress note shall indicate the patient's participation in all significant services that are provided.
(o) Discharge Criteria. A patient shall be appropriate for discharge from the inpatient service, and shall be discharged, when he or she meets one or more of the following criteria:
(1) the patient has accomplished the goals and objectives which were identified in the individual treatment plan;
(2) the patient refuses further care;
(3) the patient has been referred to other appropriate treatment which cannot be provided in conjunction with the inpatient service;
(4) the patient has been removed from the service by the criminal justice system or other legal process;
(5) the patient has received maximum benefit from the service; or
(6) the individual is disruptive to the service and/or fails to comply with the service's reasonably applied written behavioral standards.
(p) Discharge planning. The discharge planning process shall begin as soon as the patient is admitted to the inpatient service and shall be considered a part of the treatment planning process. The discharge plan shall be developed in collaboration with the patient and any significant other(s) the patient chooses to involve. If the patient is a minor, the discharge plan must also be developed in consultation with his or her parent or guardian, unless the minor is being treated without parental consent as authorized by Mental Hygiene Law Section 22.11.
(q) No patient shall be discharged without a discharge plan which has been completed and reviewed by the multi-disciplinary team prior to the discharge of the patient. This review may be part of a regular treatment plan review. The portion of the discharge plan which includes the referrals for continuing care shall be given to the patient upon discharge. This requirement shall not apply to patients who leave the inpatient service without permission, refuse continuing care planning, or otherwise fail to cooperate.
(r) The discharge plan shall be developed by the responsible clinical staff member, who, in the development of such plan, shall consider the patient's self-reported confidence in maintaining abstinence and following an individualized relapse prevention plan. The responsible clinical staff member shall also consider an assessment of the patient's home and family environment, vocational/educational/employment status, and the patient's relationships with significant others. The purpose of the discharge plan shall be to establish the level of clinical and social resources available to the patient upon discharge from the inpatient service and the need for the services for significant others. The discharge plan shall include, but not be limited to, the following:
(1) identification of continuing chemical dependence services and any other treatment, rehabilitation, self-help and vocational, educational and employment services the patient will need after discharge;
(2) identification of the type of residence, if any, that the patient will need after discharge;
(3) identification of specific providers of these needed services; and
(4) specific referrals and initial appointments for these needed services.
(s) A discharge summary which includes the course and results of care and treatment must be prepared and included in each patient's case record within twenty days of discharge.
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