Subchapter D. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIESRESIDENTIAL TREATMENT AND REHABILITATION
711.51. Intake and admission.
711.52. Treatment and rehabilitation services.
711.53. Client records.
711.54. Project management services.
711.55. Uniform Data Collection System.
711.56. Notification of termination.
711.58. Medication control.
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).
§ 711.51. 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 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.
§ 711.52. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services, which shall include, but not be limited to:
(1) Defined target population.
(2) Treatment models utilized by the project.
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
(c) 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.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
§ 711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the clients involvement with the project. In addition to the requirements contained in § 115.32 (relating to contents), the client record shall include the following:
(1) Drug and alcohol consent forms.
(2) Record of services provided.
(3) Referral contact.
(4) Progress notes.
(5) Individualized drug and alcohol treatment and rehabilitation plan.
(6) Aftercare plan, if applicable.
(7) Follow-up information.
(8) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
(b) 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 complies with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but is not 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.
§ 711.54. Project management services.
(a) When food is prepared at the project site and preparation is not directly supervised by the parent health care facility, then the drug and alcohol project shall have written policies and procedures for its dietetic services which includes, but is 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 areas.
(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.
§ 711.55. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Departments UDCS.
§ 711.56. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the clients treatment at the project. The notice shall include the reason for termination.
§ 711.57. [Reserved].
§ 711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(1) Administration of medication.
(2) Drug storage areas.
(3) Inspection of storage areas.
(4) Methods for control and accountability of drugs.
(5) Security of drugs.
(7) Medication errors and drug reactions.
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