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
Section 818.4 - Post-admission procedures
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 818.4
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Post-admission.
(1) As soon
as possible after admission, for all patients, all programs must:
(i) offer viral hepatitis testing; testing
may be done on site or by referral;
(ii) offer HIV testing; testing may not be
conducted without patient written informed consent except in situations
specifically authorized by law; testing may be done on site or by referral;
individuals on a regimen of pre- or post-exposure prophylaxis, must be
permitted to continue the regimen until consultation with the prescribing
professional occurs.
(2)
If clinically indicated, all programs must:
(i) conduct an intradermal skin or
blood-based Tuberculosis test; testing may be done on site or by referral with
results as soon as possible after testing; for patients with a positive test
result, refer the patient for further tuberculosis evaluation.
(ii) offer testing for other sexually
transmitted infections; testing may be done on site or by referral;
(iii) provide or recommend 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.
(3) As soon as
possible after testing programs must explain any blood and skin test results to
the patient.
(b) Initial evaluation.
(1) The
goal of the initial evaluation, to be completed within twenty-four (24) hours
of admission, shall be to obtain whatever relevant information is necessary to
develop an individualized patientcentered treatment/recovery plan. The initial
evaluation shall comprise a written report of findings and conclusions and
shall include the names of any staff or other persons participating in the
evaluation.
(2) Initial services.
Th initial 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 treatment plan. The initial services
shall be based on goals the patient identifies for
treatment.
(c) Medical history.
(1) For
those patients who do not have available a medical history and no physical
examination has been performed within twelve (12) months, within three (3) 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:
(i) complete blood count and
differential;
(ii) routine and
microscopic urinalysis;
(iii) if
medically or clinically indicated, urine screening for drugs;
(iv) intradermal PPD, given and interpreted
by the medical staff unless the patient is known to be PPD positive;
(v) 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 twelve (12)
months prior to admission, or if the patient is being admitted directly to the
inpatient service from another substance use disorder 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.
(d) Referral and connection.
(1) If the initial evaluation indicates that
the individual needs services beyond the capacity of the inpatient program to
provide either alone or in conjunction with another program, referral and
connection to appropriate services shall be made. Identification of such
referrals and connections and the results of those referrals to identified
program(s) shall be documented in the patient record.
(2) If a patient is referred directly to the
inpatient program from another program certified by the Office, or is
readmitted to the same program within sixty (60) days of discharge, the
existing level of care determination and evaluation or treatment/recovery plan
may be used, provided that documentation is maintained demonstrating a review
and update.
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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