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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 817. CHEMICAL DEPENDENCE RESIDENTIAL REHABILITATION SERVICES FOR YOUTH
Date:
08/31/2009
Document:
ยง 817.4 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 as determined by a face to face interview with a qualified health professional.
(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 seven 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) family history;
(iv) 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 significant others, history of the use of chemicals by significant others, and the impact of the use of chemicals on significant others;
(D) an assessment of the patient's individual, social, vocational 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 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.
(6) The comprehensive evaluation shall recognize and reflect the culture(s) of the patient as well as relevant individual preferences.
(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 seven days after admission the patient's medical history shall be recorded and placed in the patient's 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 which must be ordered within seven days of admission:
(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; and
(e) 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 service provider from another chemical dependence service provider 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 and medical history are 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 a Part 816 crisis service; and
(6) can benefit from continued treatment in the service provider.
(d) If the comprehensive evaluation and medical history indicate that the individual needs services beyond the capacity of the service provider 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 service provider from another service provider certified by the Office, or is readmitted to the same service provider 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 preliminary written individual treatment plan addressing the patient's immediate needs and prescribing a list of scheduled activities shall be developed and implemented within three days after admission. A comprehensive written individual treatment plan ("the treatment plan") shall be developed and implemented within fourteen days after admission to meet the identified needs of the patient in all areas of functioning, including but not limited to, social, emotional, familial, educational and vocational, legal, mental and physical health, as well as addiction. For patients transferring directly from one chemical dependence service to another, an updated treatment plan shall be acceptable.
(g) The treatment plan shall take into account cultural and social factors as well as the particular characteristics, conditions and circumstances of the patient. Parental or guardian involvement in the planning process, if any, must be documented.
(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 and long 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"); and
(7) include each diagnosis for which the patient is in need of treatment.
(j) When a service is to be provided by any entity other than the Part 817 service itself, 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. The criteria for successful completion of treatment and discharge shall be specified in the treatment plan.
(l) Review of treatment plans. The treatment plan shall be reviewed, signed and dated by the responsible clinical staff member within fourteen days after admission. Once established, the treatment plan shall be reviewed and revised at least every thirty days thereafter by the responsible clinical staff member in consultation with the patient and the multidisciplinary team as defined in Sections 817.8(v) of this Part. The names of all reviewing individuals shall be recorded in the treatment plan. A summary of the patient's progress in each of the specified treatment plan goals shall be prepared and documented in the patient record as part of the treatment plan review. The treatment plan shall be reviewed, certified, signed and dated by a physician who has knowledge of the patient's situation within fourteen days after admission and every thirty days thereafter.
(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 provider must be discussed at a case conference by the multidisciplinary team and the treatment plan revised accordingly.
(n) Documentation of treatment.
(1) Progress notes shall be written, signed and dated by the responsible clinical staff member no less often than once per week.
(2) Progress notes shall provide a chronology of the patient's progress related to the goals established in the treatment plan and be sufficient to delineate the course and results of treatment. The progress notes shall indicate the patient's participation in all significant services that are provided. Summaries of any case conferences, treatment plan updates, and special consultations shall be included.
(o) Discharge criteria. A patient shall be appropriate for discharge from the 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 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;
(6) the patient is disruptive to the service and/or fails to comply with the service's reasonably applied written behavioral standards; or
(7) the patient may be discharged or retained after the age of 21, if clinically appropriate, however no Medicaid reimbursement is available after the patient reaches the age of 22.
(p) Discharge planning. The discharge planning process shall begin as soon as the patient is admitted to the service and shall be considered a part of the treatment planning process. The purpose of the discharge plan is to establish the level of clinical and social resources available to the patient upon discharge and the need for services for significant others. The discharge plan shall be developed in collaboration with the patient and any significant other(s) the patient chooses to involve, as clinically appropriate. If the patient is under the age of 18, the discharge plan must also be developed in consultation with his or her parent or guardian, unless the patient 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 service provider without permission, refuse continuing care planning, otherwise fail to cooperate, or who are transferred to a higher level of care.
(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, criminal justice status, and the patient's relationships with 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, vocational, educational, medical, social, and employment services the patient will need after discharge, including identification of continuing care and community support staff;
(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 record within twenty days of discharge.
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