Current through Vol. 42, No. 1, September 16, 2024
All SUD services provided in residential treatment
facilities are rendered as a result of an individual assessment of the member's
needs and documented in the service plan.
(1)
Assessment. A
biopsychosocial assessment shall be completed for members receiving ASAM Level
3.1, 3.3, or 3.5 services, including dependent children receiving services from
the residential SUD provider, to gather sufficient information to assist the
member in developing an individualized service plan. The assessment must also
list a diagnosis that corresponds to current Diagnostic and Statistical Manual
of Mental Disorders (DSM) standards and the member's past and current
psychiatric medications. The assessment must be completed by an LBHP or
licensure candidate. Licensure candidate signatures must be co-signed by a
fully-licensed LBHP in good standing. Assessments for ASAM Level 3.7 services
shall be completed in accordance with (E) below.
(A)
Assessments for adolescents.
A biopsychosocial assessment using the Teen Addiction Severity Index (T-ASI)
shall be completed. A physical examination shall be conducted by a licensed
physician to include, at a minimum, a physical assessment, health history,
immunization status, and evaluation of motor development and function, speech,
hearing, visual, and language functioning.
(B)
Assessments for adults. A
biopsychosocial assessment using the Addiction Severity Index (ASI) shall be
completed.
(C)
Assessments
for dependent children. Assessment of children (including infants)
accompanying their parent into treatment and receiving services from the
residential SUD provider shall include the following items:
(i) Parent-child relationship;
(ii) Physical and psychological development;
(iii) Educational needs;
(iv) Parent related issues; and
(v) Family issues related to the
child.
(D)
Assessments for parents/pregnant women. Assessment of the parent
and/or pregnant women bringing their children into treatment shall include the
following items:
(i) Parenting
skills;
(ii) Knowledge of age
appropriate behaviors;
(iii)
Parental coping skills;
(iv)
Personal issues related to parenting; and
(v) Family issues as related to the
child.
(E)
Assessments for medically supervised withdrawal management. In
accordance with OAC
450:18-13-61, a medical
assessment for the appropriateness of placement shall be completed and
documented by a licensed physician during the admission process. The assessment
shall provide a diagnosis that corresponds to current DSM standards.
(F)
Assessment timeframes.
Biopsychosocial assessments shall be completed within two (2) days of admission
or during the admission process for medically supervised withdrawal
management.
(2)
Service plan. Pursuant to OAC
450:18-7-81, a service plan shall
be completed for each member receiving ASAM Level 3.1, 3.3, or 3.5 services,
including dependent children receiving services from the residential SUD
provider. The service plan is performed with the active participation of the
member and a support person or advocate, if requested by the member. In the
case of children under the age of sixteen (16), it is performed with the
participation of the parent or guardian, if allowed by law, and the child as
age and developmentally appropriate. Service plans for ASAM Level 3.7 services
shall be developed in accordance with (D) below.
(A)
Service plan development.
The service plan shall:
(i) Be completed by
an LBHP or licensure candidate. Licensure candidate signatures must be
co-signed by a fully-licensed LBHP in good standing.
(ii) Provide the formation of measurable
service objectives and reflect ongoing changes in goals and objectives based
upon member's progress or preference or the identification of new needs,
challenges, and problems.
(iii) Be
developed after and based on information obtained in the assessment and
includes the evaluation of the assessment information by the clinician and the
member.
(iv) Have an overall
general focus on recovery which, for adults, may include goals like employment,
independent living, volunteer work, or training, and for children, may include
areas like school and educational concerns and assisting the family in caring
for the child in the least restrictive level of care.
(B)
Service plan content.
Service plans must include dated signatures for the member [if age fourteen
(14) or older], the parent/guardian (if required by law), and the LBHP or
licensure candidate. Licensure candidate signatures must be co-signed by a
fully-licensed LBHP in good standing. If the member is eligible to self-consent
to treatment pursuant to state law, a parent/guardian signature is not
required. Signatures must be obtained after the service plan is completed. The
contents of a service plan shall address the following:
(i) Member strengths, needs, abilities, and
preferences;
(ii) Identified
presenting challenges, needs, and diagnosis;
(iii) Goals for treatment with specific,
measurable, attainable, realistic, and time-limited objectives;
(iv) Type and frequency of services to be
provided;
(v) Description of
member's involvement in, and response to, the service plan;
(vi) The service provider who will be
rendering the services identified in the service plan; and
(vii) Discharge criteria that are
individualized for each member and beyond that which may be stated in the ASAM
criteria.
(C)
Service plan updates. Service plan updates shall occur a minimum
of once every thirty (30) days while services are provided. Service plan
updates must include dated signatures for the member [if age fourteen (14) or
older], the parent/guardian (if required by law), and the LBHP or licensure
candidate. Licensure candidate signatures must be co-signed by a fully-licensed
LBHP in good standing. If the member is eligible to self-consent to treatment
pursuant to state law, a parent/guardian signature is not required. Signatures
must be obtained after the service plan is completed. Service plan updates
shall address the following:
(i) Progress on
previous service plan goals and/or objectives;
(ii) A statement documenting a review of the
current service plan and an explanation if no changes are to be made to the
service plan;
(iii) Change in goals
and/or objectives based upon member's progress or identification of new needs
and challenges;
(iv) Change in
frequency and/or type of services provided;
(v) Change in staff who will be responsible
for providing services on the plan; and
(vi) Change in discharge
criteria.
(D)
Service plans for medically supervised withdrawal management.
Pursuant to OAC
450:18-7-84, a service plan shall
be completed for each member receiving ASAM Level 3.7 services that addresses
the medical stabilization treatment and services needs of the member. Service
plans shall be completed by a licensed physician or licensed registered nursing
staff and must include a dated signature of the member [if age fourteen (14) or
older], the parent/guardian (if required by law), and the primary service
practitioner. The service plan shall provide a diagnosis that corresponds to
current DSM standards.
(E)
Service plan timeframes. Service plans shall be completed within
four (4) days of admission, except for service plans for individuals receiving
medically supervised withdrawal management services, which must be completed
within three (3) hours of admission.
(3)
Progress notes. Progress
notes shall chronologically describe the services provided, the member's
response to the services provided, and the member's progress in treatment.
(A)
Content. Progress notes
shall address the following:
(i)
Date;
(ii) Member's name;
(iii) Start and stop time for each timed
treatment session or service;
(iv)
Dated signature of the service provider;
(v) Credentials of the service
provider;
(vi) Specific service
plan needs, goals and/or objectives addressed;
(vii) Services provided to address needs,
goals, and/or objectives;
(viii)
Progress or barriers to progress made in treatment as it relates to the goals
and/or objectives;
(ix) Member (and
family, when applicable) response to the session or service provided;
and
(x) Any new needs, goals and/or
objectives identified during the session or service.
(B)
Frequency. Progress notes
shall be completed in accordance with the following timeframes:
(i) Progress notes for therapy, crisis
intervention and care management must be documented in an individual note and
reflect the content of each session provided.
(ii) Documentation for rehabilitation and
community recovery support services must include daily member sign-in/sign-out
record of member attendance (including date, time, type of service and service
focus), and a daily progress note or a summary progress note weekly.
(4)
Transition/discharge planning. All facilities shall assess each
member for appropriateness of discharge from a treatment program. Each member
shall be assessed using the ASAM placement tool to determine a clinically
appropriate setting in the least restrictive level of care.
(A)
Transition/discharge plans.
Transition/discharge plans shall be developed with the knowledge and
cooperation of the member. The transition/discharge plan shall be included in
the discharge summary. The discharge plan is to include, at a minimum,
recommendations for continued treatment services and other appropriate
community resources. Appointments for outpatient therapy and other services, as
applicable, should be scheduled prior to discharge from residential care.
Development of the transition/discharge plan shall begin no later than two (2)
weeks after admission.
(B)
Discharge summary. The discharge summary shall document the
member's progress made in treatment and response to services rendered. A
completed discharge summary shall be entered in each member's record within
fifteen (15) days of the member completing, transferring, or discontinuing
services. The summary must be signed and dated by the staff member completing
the summary.
