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Pennsylvania Code



711.81.    Intake and admission.
711.82.    Treatment and rehabilitation services.
711.83.    Client records.
711.84.    Project management services.
711.85.    Uniform Data Collection System.
711.86.    Notification of termination.
711.87.    Medication control.
711.88.    [Reserved].

§ 711.81. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which shall include, but not be 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 shall include, 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, if applicable.

   (6)  Psychosocial evaluation.

   (7)  Preliminary treatment and rehabilitation plan.

§ 711.82. Treatment and rehabilitation services.

 (a)  The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not 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.

 (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. The following services shall be included and documented:

   (1)  Individual counseling, at least twice weekly.

   (2)  Group counseling, at least twice weekly.

   (3)  Family counseling, as appropriate.

   (4)  Couple counseling, as appropriate.

 (g)  The project shall assist the client in obtaining the following supportive services when necessary:

   (1)  Medical/dental.

   (2)  Psychiatric.

   (3)  Legal.

   (4)  Economic.

   (5)  Educational.

   (6)  Vocational.

   (7)  Recreational/social.

§ 711.83. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Referral contact.

   (3)  Individualized drug and alcohol treatment and rehabilitation plan.

   (4)  Progress notes.

   (5)  Aftercare plans, if applicable.

   (6)  Record of services provided.

   (7)  Follow-up information.

   (8)  Verification that work done by the client at the project is an integral part of this 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 that director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (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 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 or organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of the client or guardian.

     (v)   The dated signature of a 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.

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

§ 711.84. Project management services.

 (a)  The partial hospitalization 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 partial hospitalization project.

 (b)  The hours of project operation shall be displayed conspicuously to the general public.

 (c)  A telephone number shall be displayed conspicuously to the general public for emergency purposes.

 (d)  The project shall develop a written aftercare policy.

 (e)  The project shall develop a written follow-up policy.

 (f)  The 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.

§ 711.85. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A data collection shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.86. Notification of termination.

 (a)  The project director 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 to terminate treatment.

§ 711.87. 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 includes, but is not 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.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

§ 711.88. [Reserved].


   The provisions of this §  711.88 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210302).

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