Subchapter E. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIESRESIDENTIAL TREATMENT AND REHABILITATION
709.51. Intake and admission.
709.52. Treatment and rehabilitation services.
709.53. Client records.
709.54. Project management services.
This subchapter cited in 31 Pa. Code § 89.622 (relating to nonhospital, residential treatment and rehabilitation services); and 37 Pa. Code § 451.121 (relating to Residential Inpatient Drug and Alcohol Program).
§ 709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
(2) Treatment methodology.
(3) Requirements for completion of treatment.
(4) Involuntary discharge/termination criteria.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
(ii) Hours of operation.
(iii) Fee schedule.
(iv) Services provided.
(3) Histories, which include the following:
(i) Medical history.
(ii) Drug or alcohol history, or both.
(iii) Personal history.
(4) Consent to treatment.
(5) Physical examination.
(6) Psychosocial evaluation.
(7) Preliminary treatment and rehabilitation plan.
§ 709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
(2) Type and frequency of treatment and rehabilitation services.
(3) Proposed type of support service.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
§ 709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the clients involvement with the project. This shall include, but not be limited to, the following:
(1) Consent forms.
(2) Medication records.
(3) Record of services provided.
(4) Referral contact.
(5) Progress notes.
(6) Individualized treatment and rehabilitation plan.
(7) Client-related correspondence.
(8) Case consultation notes.
(9) Aftercare plan, if applicable.
(10) Discharge summary.
(11) Follow-up information.
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
(13) Documentation of special dietetic needs, if applicable.
(b) The project shall develop and maintain client records on standardized project client record forms.
§ 709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
(2) Receiving, storing and preserving of food stuff.
(3) Proper preparation of food.
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
(5) Personal hygiene for those in food preparation areas.
(6) Special dietary needs.
(b) The project shall develop a written client aftercare policy.
(c) The project shall develop a written client follow-up policy.
(d) The project shall develop a written plan providing for outreach services which includes, but is not 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.
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