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Pennsylvania Code



Subchapter C. GENERAL STANDARDS FOR FREESTANDING
TREATMENT ACTIVITIES


Sec.


709.21.    Applicability.
709.22.    Governing body.
709.23.    Project director.
709.24.    Treatment/rehabilitation management.
709.25.    Fiscal management.
709.26.    Personnel management.
709.27.    [Reserved].
709.28.    Confidentiality.
709.29.    Retention of client records.
709.30.    Client rights.
709.31.    Data collection system.
709.32.    Medication control.
709.33.    Notification of termination.
709.34.    Reporting of unusual incidents.

Cross References

   This subchapter cited in 28 Pa. Code §  709.121 (relating to applicability); 37 Pa. Code §  451.111 (relating to Alcohol or Drug Outpatient Treatment Program); and 37 Pa. Code §  451.121 (relating to Residential Inpatient Drug and Alcohol Program).

§ 709.21. Applicability.

 (a)  The intake, evaluation and referral, inpatient nonhospital, partial hospitalization, outpatient and inpatient hospital activities shall comply with this chapter.

 (b)  A facility in which freestanding treatment activities are provided that has a valid full license from the Department of Public Welfare under 55 Pa. Code Chapters 5300 and 5310 (relating to private psychiatric hospitals; and community residential rehabilitation services for the mentally ill) is deemed to be in compliance with § §  709.22—709.26, 709.29 and 709.32. This subsection shall remain in effect as long as the Department finds the standards in 55 Pa. Code Chapters 5300 and 5310 to be consistent with the requirements of this subchapter.

Authority

   The provisions of this §  709.21 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.21 amended December 5, 1997, effective December 6, 1997, 27 Pa.B. 6330; amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (293154) to (293155).

§ 709.22. Governing body.

 (a)  A project shall have a governing body and legal responsibility for the project rests in the governing body.

 (b)  The duties of the governing body include, but are not limited to, the following:

   (1)  Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.

   (2)  Identifying the project’s purpose and philosophy directly related to drug and alcohol services.

   (3)  Documenting the project’s organizational structure.

 (c)  If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.

Authority

   The provisions of this §  709.22 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.22 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (296155) and (210257).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.23. Project director.

 Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.

Authority

   The provisions of this §  709.23 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.23 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial page (210257).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.24. Treatment/rehabilitation management.

 (a)  The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:

   (1)  Definition of the target population toward whom facility services are directed.

   (2)  Identification of the treatment models and practices utilized by the project.

   (3)  Written procedures for the management of treatment/rehabilitation services for clients.

   (4)  Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.

 (b)  The project shall maintain a current community resource listing of other health and social service agencies.

Authority

   The provisions of this §  709.24 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.24 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (210257) and (210258).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability); 28 Pa. Code §  709.41 (relating to exceptions to the general standards for freestanding treatment activities); 28 Pa. Code §  709.61 (relating to exceptions to the general standards for freestanding treatment activities); and 28 Pa. Code §  709.73 (relating to client management services).

§ 709.25. Fiscal management.

 The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project’s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.

Authority

   The provisions of this §  709.25 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.25 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial page (210258).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.26. Personnel management.

 (a)  The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:

   (1)  Utilization of volunteers.

   (2)  Rules of conduct.

   (3)  Supervision of staff.

   (4)  Orientation of new employees.

 (b)  The personnel records must include, but are not limited to:

   (1)  Application or resume for employment.

   (2)  Written verification of qualifying professional credentials.

   (3)  Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.

   (4)  Disciplinary actions.

 (c)  There shall be written job descriptions for project positions.

Authority

   The provisions of this §  709.26 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.26 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (210258) and (293157).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.27. [Reserved].


Source

   The provisions of this §  709.27 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial pages (210259) to (210260).

§ 709.28. Confidentiality.

 (a)  A written procedure shall be developed by the project director which shall comply with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:

   (1)  Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.

   (2)  Identification of project staff having access to records, and the methods by which staff gain access.

 (b)  The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.

 (c)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:

   (1)  Name of the person, agency or organization to whom disclosure is made.

   (2)  Specific information disclosed.

   (3)  Purpose of disclosure.

   (4)  Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).

   (5)  Dated signature of witness.

   (6)  Date, event or condition upon which the consent will expire.

 (d)  A copy of a client consent shall be offered to the client and a copy maintained in the client record.

 (e)  When consent is not required, the project personnel shall:

   (1)  Fully document the disclosure in the client records.

   (2)  Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.

Authority

   The provisions of this §  709.28 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.28 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial page (293158).

Cross References

   This section cited in 28 Pa. Code §  715.11 (relating to confidentiality of patient records).

§ 709.29. Retention of client records.

 (a)  Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.

 (b)  If the project discontinues operation, it shall make known to the Department where its records are stored.

Authority

   The provisions of this §  709.29 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.29 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (293158) and (210261).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.30. Client rights.

 The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.

   (1)  A client receiving care or treatment under section 7 of the act (71 P. S. §  1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.

   (2)  The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.

   (3)  Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.

   (4)  Clients have the right to appeal a decision limiting access to their records to the director.

   (5)  Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.

   (6)  Clients have the right to submit rebuttal data or memoranda to their own records.

Authority

   The provisions of this §  709.30 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.30 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial page (210261).

§ 709.31. Data collection system.

 (a)  A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance in relationship to its stated goals and objectives.

 (b)  The recordkeeping system must allow for the identification of clients’ admissions and discharges within a specific time period.

Authority

   The provisions of this §  709.31 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.31 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial page (210261).

§ 709.32.  Medication control.

 (a)  Projects furnishing pharmaceutical services shall present a license from the Department of Health’s Board of Examiners or the Department of State’s State Board of Pharmacy and a DEA registration to Department employees. Other notices of review or inspection, or both, shall be made available upon request.

 (b)  Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.

 (c)  The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:

   (1)  Administration of medication, including the documentation of the administration of medication:

     (i)   By individuals permitted to administer by Pennsylvania law.

     (ii)   When self administered by the client.

   (2)  Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.

   (3)  Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:

     (i)   What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.

     (ii)   Disinfectants and drugs for external use are stored separately from oral and injectable drugs.

     (iii)   Drugs requiring special conditions for storage to insure stability are properly stored.

     (iv)   Outdated drugs are removed.

     (v)   Copies of drug-related regulations are available in appropriate areas.

   (4)  Methods for control and accountability of drugs, including, but not limited to:

     (i)   Who is authorized to remove drug.

     (ii)   The program’s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.

   (5)  Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.

   (6)  Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.

Authority

   The provisions of this §  709.32 amended under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.32 amended October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660. Immediately preceding text appears at serial pages (210261) to (210262).

Cross References

   This section cited in 28 Pa. Code §  709.21 (relating to applicability).

§ 709.33. Notification of termination.

 (a)  Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision terminating treatment.

Cross References

   This section cited in 28 Pa. Code §  709.41 (relating to exceptions to the general standards for freestanding treatment facilities).

§ 709.34. Reporting of unusual incidents.

 (a)  The project shall develop and implement policies and procedures to respond to the following unusual incidents:

   (1)  Physical assault or sexual assault by staff or a client.

   (2)  Selling or use of illicit drugs on the premises.

   (3)  Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.

   (4)  Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.

   (5)  Theft, burglary, break-in or similar incident at the facility.

   (6)  Event at the facility requiring the presence of police, fire or ambulance personnel.

   (7)  Fire or structural damage to the facility.

   (8)  Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.

 (b)  Policies and procedures must include the following:

   (1)  Documentation of the unusual incident.

   (2)  Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.

   (3)  Implementation of a timely and appropriate corrective action plan, when indicated.

   (4)  Ongoing monitoring of the corrective action plan.

   (5)  Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.

 (c)  To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:

   (1)  Physical or sexual assault by staff or a client.

   (2)  Death or serious injury due to trauma, suicide, medication error or unusual circumstances.

   (3)  Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.

   (4)  Event at the facility requiring the presence of police, fire or ambulance personnel.

   (5)  Outbreak of a contagious disease requiring CDC notification.

Authority

   The provisions of this §  709.34 issued under section 2301-A of The Administrative Code of 1929 (71 P. S. §  613.1).

Source

   The provisions of this §  709.34 adopted October 17, 2014, effective October 18, 2014, 44 Pa.B. 6660.



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