New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 817 - Substance Use Disorder Residential Rehabilitation Services for Youth (RRSY)
Section 817.5 - Treatment / recovery plan
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 817.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Treatment / recovery plan. Each patient must have a written patient-centered treatment/recovery plan developed by clinical staff and patient as soon as possible after admission but not later than ten (10) calendar days after admission. Standards for developing a treatment/recovery plan include, but are not limited to:
(1) The
treatment/recovery plan must also be developed in consultation with the
patient's parent or guardian unless the minor is being treated without parental
consent as authorized by Mental Hygiene Law section 22.11.
(2) For patients moving directly from one
program to another, the existing treatment/recovery plan may be used if there
is documentation that it has been reviewed and, if necessary, updated within
ten (10) days of transfer.
(b) Treatment/recovery plan. The treatment/recovery plan must:
(1) include
each diagnosis for which the patient is being treated;
(2) address patient identified problem areas
specified in the admission assessment and concerns which may have been
identified subsequent to admission, and identify methods and treatment
approaches that will be utilized to achieve the goals developed by the patient
and primary counselor;
(3) identify
a single member of the clinical staff responsible for coordinating and managing
the patient's treatment who shall approve and sign (physical or electronic
signature) such plan; and
(4) be
reviewed, approved, signed and dated by the physician within fourteen (14) days
after admission.
(5) Where a
service is to be provided by any other program off-site, the treatment/recovery
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.
(c) Continuing review of treatment plans.
(1) The clinical staff shall ensure that the
treatment/recovery plan is included in the patient record and that all
treatment is provided in accordance with the individual treatment/recovery
plan.
(2) If, during the course of
treatment, revisions to the treatment/recovery plan are determined to be
clinically necessary, the plan shall be revised accordingly by the clinical
staff member.
(3) The
treatment/recovery plan must be reviewed, and revised if necessary, at least
once within every thirty (30) calendar days from the date of admission. Reviews
should occur more frequently when a patient is not responding to treatment as
planned or if a significant incident occurs. Reviews of the treatment plan
shall be signed (physical or electronic signature) by a
physician.
(d) Progress notes.
(1) A
progress note shall be written, signed and dated by the clinical staff member
or another clinical staff member familiar with the patient's care no less often
than once per week. Such progress note shall provide a chronology of the
patient's participation in all significant services provided, their progress
related to the initial services or the goals established in the
treatment/recovery plan and be sufficient to delineate the course and results
of treatment/services.
(e) Discharge and planning for level of care transitions.
(1) The
discharge planning process shall begin as soon as the patient is admitted and
shall be considered a part of the treatment planning process. The plan for
discharge and level of care transitions 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 plan must also be developed in consultation with
the patient's parent or guardian, unless the minor is being treated without
parental consent as authorized by Mental Hygiene Law Section 22.11.
(2) Discharge should occur when:
(i) the patient meets criteria documented by
the OASAS level of care determination protocol for an alternate level of care
and has attained skills necessary to identify and manage cravings and urges to
use substances, stabilized psychiatric and medical conditions, and has
identified a plan for returning to their community;
(ii) the patient has received maximum benefit
from the service provided by the program; or
(iii) the individual is disruptive and/or
fails to comply with the program's reasonably applied written behavioral
standards, provided the individual is offered a referral to another treatment
program and discharge is otherwise in accordance with Part 815 of this
Title.
(3) 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/recovery plan review. The
portion of the discharge plan which includes the referrals for postdischarge
shall be given to the patient. This requirement shall not apply to patients who
leave the program without permission, refuse continuing care planning, or
otherwise fail to cooperate.
(4)
The discharge plan shall be developed by the clinical staff member, who, in the
development of such plan, shall consider the patient's self-reported confidence
in maintaining their health and recovery and following an individualized safety
plan. The 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 individual post-treatment and the need for the
services for significant others. The plan shall include, but not be limited to,
the following:
(i) identification of any
other treatment, rehabilitation, self-help and vocational, educational and
employment services the patient will need after discharge;
(ii) identification of the type of residence,
if any, that the patient will need after discharge;
(iii) identification of specific providers of
these needed services;
(iv) specific
referrals and initial appointments for these needed services;
(v) the patient, and their family/significant
other(s) shall be offered naloxone education and training and a naloxone kit or
prescription; and
(vi) an
appointment with a community based provider to continue access to medication
for addiction treatment.
(5) 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 (20) days of discharge.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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