New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 37E - OUTPATIENT SERVICE STANDARDS
Subchapter 2 - PROGRAM OPERATION
Section 10:37E-2.3 - Services to be provided

Universal Citation: NJ Admin Code 10:37E-2.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The OP program shall provide a range of services which address the individual needs of clients and shall include, at a minimum, the following:

1. Assessment and evaluation;

2. Referral, linkage and follow-up services;

3. Individual, group, and family therapy;

4. Psychiatric evaluation, medication services and medication monitoring; and

5. Psychoeducational services.

(b) Progress notes shall be completed after each OP session and shall be entered chronologically in the client record to document service provision.

(c) Progress notes shall generally relate the treatment provided to the goals and objectives contained in the written service plan and, at a minimum, shall address the following:

1. All face-to-face and other pertinent contacts;

2. Amount of time it took to deliver the service;

3. Clinical course of treatment including rationale for service provided;

4. Significant changes in the client's condition or situation, if any; and

5. Current status and response to treatment.

(d) The PA shall develop and implement policies and procedures to ensure effective provision of medication monitoring services.

1. Methods for service coordination and communication between PAs and other service providers serving mutual clients receiving medication shall be developed and implemented consistent with confidentiality rules in N.J.A.C. 10:37-6.59 to ensure that all providers of service are aware of the medication prescribed, potential side effects, and other medication monitoring concerns.

2. The PA shall ensure that clients receive information and instructions about the medication prescribed including, at a minimum, dosage, administration, contraindications, potential adverse reactions, and any relevant health education.

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