Subchapter D. STANDARDS FOR INTAKE, EVALUATION AND
709.41. Exceptions to the general standards for freestanding treatment activities.
709.42. Project management.
709.43. Client management.
709.44. Client records.
§ 709.41. Exceptions to the general standards for freestanding treatment activities.
Due to the nature of intake, evaluation and referral, projects of this kind need not comply with the following sections:
(1) Section 709.24(a)(2) and (3) (relating to treatment/rehabilitation management).
§ 709.42. Project management.
(a) The intake project shall have a written procedure for the performance of the following functions:
(1) Orientation of the client to the drug or alcohol service delivery system, or both.
(2) Thorough exploration of service needs and discussion with the client concerning service options to which he may be referred.
(3) Development of a confidential history, including significant medical, social, drug and alcohol, occupational and family information.
(4) Prompt arrangement for delivery of the requested services.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(1) Arrangement for the provision of needed medical, functional, psychological, psychiatric, social or vocational diagnostic assessments.
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
(c) The intake project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
(2) Alerting persons and their families to the availability of project services.
(3) Encouraging persons to utilize the service delivery system.
(d) The intake project shall operate at least 5 days of the week and for a minimum of 40 hours per week. Additional hours should be appropriate to the population served by the intake project.
(e) The hours of operation shall be displayed conspicuously to the general public.
(f) A telephone number shall be displayed conspicuously to the general public.
(g) Procedures to be followed in psychiatric and medical emergencies shall be clearly specified in writing and made readily available to the staff.
§ 709.43. Client management.
(a) The intake project shall have written policies and procedures for communication with law-enforcement authorities, local or State health or welfare authorities, as appropriate, regarding clients whose condition or its cause is reportable; for example, persons having contagious diseases or victims of suspected criminal acts, such as rape or gunshot wounds, 18 Pa.C.S. § 5106 (relating to failure to report injuries by firearm or criminal act) and child abuse under the Child Protective Services Law (11 P. S. § § 22012224).
(b) The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:
(1) Individuals who lose consciousness.
(3) Individuals with communicable disease.
(4) Individuals requiring transfer to a hospital or other treatment facility.
(5) Individuals requiring detoxification.
(c) Clients shall be observed upon intake for withdrawal symptoms from substances abused. If serious symptoms of drug/alcohol abuse or dependence or other physical problems are observed, prompt medical attention shall be obtained. Data obtained during the observation period shall be recorded.
(d) If possible, the client should be transported to the selected referral agency/resource.
§ 709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(i) Medical history.
(ii) Drug or alcohol history, or both.
(iii) Personal history.
(2) Consent forms.
(3) Psychosocial evaluation.
(4) Referral contact.
(5) Record of services provided.
(b) If applicable, the project shall also include the following items in the client record:
(1) Results of physical examination.
(2) Medication records.
(3) Treatment and rehabilitation plans.
(4) Follow-up information.
(c) The project shall develop and maintain client records on standardized project client record forms.
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