Subchapter C. STANDARDS FOR INTAKE EVALUATION AND
711.41. Project management.
711.42. Client management.
711.43. Client records.
711.44. Uniform Data Collection System.
§ 711.41. 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 personal history, including significant medical, social, drug or alcohol, occupational and family information.
(4) Prompt arrangement for delivery of the requested services.
(b) The intake project or treatment project 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. The plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The plan shall also include a 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.
(h) The intake process shall proceed expeditiously to avoid discouragement and should not exceed a period of 48 hours.
§ 711.42. 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 diseases.
(4) Individuals requiring transfer to a hospital or other treatment facility.
(5) Individuals requiring detoxification.
(c) A client 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) The client should be transported to the selected referral agency/resource, if possible.
§ 711.43. Client records.
(a) Record requirements. The project shall maintain a client record on an individual. In addition to the requirements contained in § 115.32 (relating to contents), the client record shall include the following:
(1) Histories, which include the following:
(i) Medical history.
(ii) Drug or alcohol history.
(iii) Personal history.
(2) Drug and alcohol consent forms.
(3) Psychosocial evaluation.
(4) Referral contact.
(5) Record of services provided.
(b) Additional information. If applicable, the project shall include the following items in the client record:
(1) Drug and alcohol treatment and rehabilitation plans.
(2) Follow-up information.
(c) Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record 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 and kept on file.
(1) 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 shall include, but not be limited to:
(i) Confidentiality of client identity and records.
(ii) Staff access to client records.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency, organization to whom disclosure is made.
(ii) The specific information disclosed.
(iii) The purpose of disclosure.
(iv) The dated signature of client or guardian.
(v) The dated signature of witness.
(vi) The expiration date of the consent.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
(4) Where consent is not required, the project personnel shall:
(i) Fully document the disclosure in the client records.
§ 711.44. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Departments UDCS.
§ 711.45. [Reserved].
The provisions of this § 711.45 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210287).
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