Current through Register Vol. 46, No. 39, September 25, 2024
(a) As soon
as possible after admission, if not completed already, all programs must:
(1) offer viral hepatitis testing (testing
may be done by referral);
(2) offer
HIV testing (testing may not be conducted without a resident's written informed
consent in accordance with public health law and may be done on site or by
referral). Residents on a regimen of pre- or post- exposure prophylaxis must be
permitted to continue the regimen until consultation with the prescribing
professional occurs.
(3) Screen for
co-occurring mental health conditions and behavioral health risks, including
suicide risk, using validated screening instruments approved by the
Office.
(4) If clinically
appropriate, all programs must:
(i) conduct a
blood-based tuberculosis test (testing may be done on site or by referral with
results as soon as possible after testing); residents with a positive test
result should be referred for further tuberculosis evaluation;
a. an intradermal PPD may be placed in those
circumstances when a blood-based tuberculosis test cannot be performed unless
the patient is known to be PPD positive;
b. PPD placement may done on site with
medical staff interpreting the results or by referral with results as soon as
possible after testing
(ii) offer testing for other sexually
transmitted infections (testing may be done on site or by referral);
(iii) offer immunizations either on site or
by referral;
(iv) offer pregnancy
tests to persons of childbearing potential (testing may be done on site or by
referral);
(v) provide or recommend
any other tests the examining physician or other medical staff member working
within their scope of practice deems necessary including, but not limited to,
an ECG, a chest X-ray or other diagnostic tests.
(5) As soon as possible after testing,
programs must review and discuss any blood, urine, and skin test results, ECG
results, chest X-ray results, or other diagnostic test results where applicable
with the residents.
(6) Any
significant medical issues, including risk of transmissible infections,
identified prior to or after admission must be addressed in the
treatment/recovery plan and documented in the resident's record.
Treatment/recovery plans must include provisions for the prevention, care, and
treatment of HIV, viral hepatitis, tuberculosis, sexually transmitted
infections, and other infectious diseases when present. If a resident chooses
not to obtain such care and treatment, the provider must have the resident
acknowledge in writing that such care and treatment were offered and
declined.
(b)
Comprehensive evaluation.
(1) The goal of the
comprehensive evaluation shall be to obtain information from the resident and
other sources, including family members and significant others if possible and
where appropriate, that is necessary to develop an individualized,
person-centered treatment/recovery plan.
(2) No later than fourteen days after
admission, staff shall complete the resident's comprehensive evaluation which
shall include a written report of findings and conclusions addressing, at a
minimum, the resident's:
(i) identifying and
emergency contact information;
(ii)
the source of referral, date of commencing service, and name of the clinical
staff member with primary responsibility for the resident;
(iii) both recent and history of substance
use;
(iv) substance use disorder
treatment history;
(v) comprehensive
psychosocial history, including, but not limited to the following:
(a) legal history;
(b) transmissible infection risk assessment
(HIV, tuberculosis, viral hepatitis, sexually transmitted infections, and other
transmissible infections);
(c) an
assessment of the resident's individual, social and educational strengths and
limitations, including, but not limited to, the resident's literacy level,
daily living skills and use of leisure time;
(d) the resident's current medical
conditions, current mental health conditions, past medical history, past mental
health history, and an assessment of the resident's risk of harming self or
others.
(3) The
comprehensive evaluation must include diagnoses, including substance-related,
medical, and psychiatric diagnoses in official nomenclature with associated
diagnostic codes in the most recent version of the Diagnostic and Statistical
Manual (DSM) or the International Classification of Diseases (ICD).
(4) The comprehensive evaluation shall bear
the names of the clinical staff members who evaluated the resident and must be
signed (physically or electronically) and dated by the qualified health
professional responsible for the evaluation.
(c) Medical history and physical examination.
Providers shall make every effort to execute appropriate consents to obtain and
share medical information with the resident's other medical providers as
appropriate.
(1) Residents who do not have an
available medical history and have not had a physical examination performed
within the last 12 months prior to admission must have a medical history
recorded, and a physical examination performed and documented in the resident's
record by a physician, physician assistant, or a nurse practitioner working
within their scope of practice within forty five days after admission. The
physical examination may include but shall not be limited to the investigation
of, and if appropriate, screenings for infectious diseases; pulmonary, cardiac
or gastrointestinal abnormalities; and physical, neurological, and/or
psychological 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 toxicology test;
(iv)
pregnancy test for persons of childbearing potential;
(v) blood-based tuberculosis test
(a) an intradermal PPD may be placed in those
circumstances when a blood-based tuberculosis test cannot be performed, with
the results interpreted by the medical staff working within the scope of their
practice unless the resident is known to be PPD positive;
(vi) any other tests the examining physician
or other medical staff members working within their scope of practice deem to
be necessary, including, but not limited to, an ECG, a chest X-ray, or other
diagnostic tests.
(2) If
the resident has a medical history available and has had a physical examination
performed within 12 months prior to admission, or if the resident has been
admitted directly to the residential 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. Notwithstanding the forgoing, the following shall
be offered regardless of a documented history within the previous twelve
months: HIV and viral hepatitis testing.
(i)
a focused medical history shall be taken and/or physical examination shall be
performed and/or laboratory tests and other diagnostic tests shall be ordered
if the examining physician, physician assistant, or nurse practitioner working
within the scope of their practice determine that the elements of the existing
medical history and/or physical examination and/or results of laboratory and
other diagnostic tests require reevaluation based on the clinical judgment of
the examining physician or other medical staff;
(ii) a focused medical history shall be taken
and/or physical examination shall be performed and/or laboratory and other
diagnostic tests shall be ordered if the resident has a physical complaint that
was not addressed in the existing medical history and/or physical examination,
and/or the resident has a new complaint that developed since the existing
medical history was taken and/or existing physical examination was
performed.
(3) Resident
records shall include a summary of the medical history and the results of the
physical examination, laboratory tests, and other diagnostic tests and shall
also demonstrate that appropriate medical care, including mental health care,
is recommended to any resident who needs such care.
(d) After the comprehensive evaluation is
completed, a resident shall be retained in such treatment if the resident has a
diagnosis of a substance use disorder in accordance with the most recent
edition of the Diagnostic and Statistical Manual (DSM) or the International
Classification of Diseases (ICD) and continues to meet the admission criteria
required by this Part.
(e) If the
comprehensive evaluation indicates that the resident needs services beyond the
capacity of the residential 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 resident record.
(f) If a resident is referred directly to the
residential service from another service certified by the Office, or is
readmitted to the same service within sixty (60) days of discharge, the
existing level of care determination and comprehensive evaluation may be used,
provided that the documentation has been reviewed and, if necessary, updated
within fourteen (14) days of transfer.
(g) Treatment/recovery plan. A
person-centered, initial treatment/recovery plan addressing the resident's
individual needs must be developed within three days of admission, or
readmission, to the substance use disorder residential service. The
treatment/recovery plan shall be developed by the clinical staff member with
primary responsibility for the resident ("the responsible clinical staff
member") in collaboration with the resident and anyone identified by the
resident as supportive of their recovery goals. This initial treatment/recovery
plan must contain a statement which documents that the resident meets admission
criteria for this level of care, identifies the assignment of a named clinical
staff member with the responsibility to provide orientation to the resident,
and includes a preliminary schedule of activities, therapies and
interventions.
(h) A
treatment/recovery plan, based on the admitting evaluation, shall be prepared
within thirty days of development of the initial treatment/recovery plan to
meet the identified needs of the resident, and shall take into account cultural
and social factors as well as the particular characteristics, conditions and
circumstances of each resident. For residents moving directly from one
substance use disorder service to another, the existing treatment/recovery plan
may be used if there is documentation that it has been reviewed and, if
necessary, updated to reflect the resident's goals as appropriate.
(i) The treatment/recovery plan shall:
(1) be developed by the responsible clinical
staff member(s) in collaboration with the resident and anyone identified by the
resident as supportive of their recovery goals;
(2) be based on the admitting evaluations
specified above and any additional evaluation(s) the resident has received or
is determined to be required;
(3)
specify measurable treatment goals for each problem identified;
(4) specify the objectives that shall be used
to measure progress toward attainment of goals;
(5) include schedules for the provision of
all services prescribed; where a service is to be provided by any other service
or facility offsite, the treatment/recovery plan must contain a description of
the nature of the service, a record that referral for such service has been
made, the results of the referral, and procedures for ongoing care coordination
and discharge planning;
(6) identify
the responsible clinical staff for coordinating and managing the resident's
treatment, who shall approve and sign (physically or electronically)
such;
(7) reference any significant
medical and mental health issues, including applicable medications, identified
as part of the medical assessment process;
(8) include each diagnosis for which the
resident is being treated;
(9) be
reviewed, approved, signed (physically or electronically), and dated by the
supervisor of the responsible clinical staff member within seven (7) days after
the finalization of the treatment/recovery plan. If the supervisor of the
responsible clinical staff member is not a qualified health professional,
another qualified health professional must be designated to sign (physically or
electronically) the plan; and
(10)
Pregnancies. Treatment/recovery plans must include provisions for prenatal care
for all residents who are pregnant or become pregnant. If a pregnant resident
chooses not to obtain such care, the provider must have the resident
acknowledge in writing that prenatal care was offered, recommended, and
declined. The program should offer to develop a plan of safe care with the
resident and anyone identified by the resident, and such offer should be noted
in the resident's record.
(11)
Transmissible infections. Treatment/recovery plans must include provisions for
the prevention, care, and treatment of HIV, viral hepatitis, tuberculosis,
and/or sexually transmitted infections when present. If a resident chooses not
to obtain such care and treatment, the provider must have the resident
acknowledge that such care and treatment were offered, recommended, and
declined.
(j) Treatment
according to the treatment/recovery plan. The responsible clinical staff member
shall ensure that the treatment/recovery plan is included in the resident
record and that all treatment is provided in accordance with the
treatment/recovery plan.
(1) If, during the
course of treatment, revisions to the treatment/recovery plan are determined to
be clinically necessary, a multidisciplinary case conference will be held with
the resident to determine what revisions to the treatment plan are needed to
help the resident achieve their goals.
(k) Progress notes.
(1) Progress notes shall be written, signed
(physically or electronically) and dated by the responsible clinical staff
member or another clinical staff member familiar with the resident's care no
less often than once every two weeks. Progress towards all treatment/recovery
plan goals that are made during the two-week period must be documented in the
applicable progress note.
(2)
Progress notes shall provide a chronology of the resident's progress related to
the goals established in the treatment/recovery plan and be sufficient to
delineate the course and results of treatment. The progress notes shall
indicate the resident's participation in all significant services that are
provided.
(l) Resident
deaths. If a resident dies while in active treatment any known details must be
documented in the resident record.
(m) Discharge planning. Discharge planning
shall begin upon admission and shall be considered part of the
treatment/recovery planning process. The plan for discharge shall be developed
by the responsible clinical staff member in collaboration with the resident and
anyone the resident identifies as supportive of their recovery. If the resident
is a minor, the discharge plan must also be developed in consultation with
their parent or guardian, unless the minor is being treated without parental
consent as authorized by Section 22.11 of the Mental Hygiene Law. Information
pertaining to testing and treatment of sexually transmitted infections
including HIV cannot be shared with the minor resident's parent or guardian
without the resident's consent in accordance with applicable laws and
regulations.
(1) A resident discharged from
the program must be discharged for a documented reason. Residents discharged
involuntarily must be discharged consistent with Part 815 of this
Title.
(2) The discharge plan shall
be based on the resident's self-reported confidence in their recovery and
following an individualized recovery support plan, an assessment of the
resident's home environment, suitability of housing,
vocational/educational/employment status, and relationships with significant
others to establish the level of social resources available to the resident and
the need for services to significant others. In accordance with guidance and
standards issued by the Office, the discharge plan shall include but not be
limited to:
(i) identification of continuing
substance use disorder services, medical and mental health services,
rehabilitation, recovery, wellness, and vocational, educational and employment
services the resident will need after discharge;
(ii) identification of specific providers of
these needed services; and
(iii)
specific referrals with appointment dates and times for any needed
services;
(iv) identification of
the type of residence that the resident will need after discharge;
(v) prescriptions and/or other arrangements
to ensure access to medications including medications for addiction treatment
for substance use disorders; and
(vi) overdose prevention education, naloxone
education and training, and a naloxone kit or prescription for the resident and
their family/significant other(s).
(n) No resident shall be discharged without a
discharge plan that has been reviewed and approved by the responsible clinical
staff member and the clinical supervisor or designee prior to the discharge of
the resident. The portion of the discharge plan that includes referrals for
continuing care shall be given to the resident upon discharge. Documentation
detailing why a discharge plan was not provided to the resident prior to
discharge must be placed in the resident record if the resident did not receive
the plan.
(o) Discharge criteria. A
resident shall be appropriate for discharge from the residential service and
shall be discharged when they meet one or more of the following criteria:
(1) the resident has accomplished the goals
and objectives which were identified in the treatment/recovery plan;
(2) the resident declines further
care;
(3) the resident has been
referred to other treatment that meets their individual needs and cannot be
provided in conjunction with the residential service;
(4) the resident has been removed from the
service by the criminal justice system or other legal process;
(5) the resident has received maximum benefit
from the service; and/or
(6) the
resident does not adhere to the written behavioral standards of the facility,
provided that the resident is offered a referral and connection to another
treatment program. A discharge for behavioral reasons with an offer of a
referral and connection to another treatment program shall occur only after the
program has utilized interventions to help the resident manage their behavior
in a manner consistent with the written behavioral standards of the facility,
and in accordance with guidance from the Office.
(p) A discharge summary which includes the
course and results of treatment must be prepared and included in each
resident's record within thirty (30) days of discharge.
