Subchapter H. STANDARDS FOR OUTPATIENT ACTIVITIES
711.91. Intake and admission.
711.92. Treatment and rehabilitation services.
711.93. Client records.
711.94. Project management services.
711.95. Uniform Data Collection System.
711.96. Notification of termination.
711.97. Medication control.
711.98. Physical plant.
This subchapter cited in 31 Pa. Code § 89.623 (relating to outpatient services); and 37 Pa. Code § 451.111 (relating to Alcohol or Drug Outpatient Treatment Program).
§ 711.91. 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 the following:
(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.
§ 711.92. 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. The 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 60 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.
§ 711.93. 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 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 plans, if applicable.
(7) Follow-up information.
(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 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.
§ 711.94. Project management services.
(a) Outpatient projects shall make an effort to adjust the hours of project operations to meet client needs, taking into account other client time commitments such as employment and school schedules.
(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 client aftercare policy.
(e) The project shall develop a written client follow-up policy.
(f) The project shall develop a written plan providing for outreach services which 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.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
§ 711.95. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Departments UDCS.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the projects performance.
§ 711.96. 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.
(b) The client shall have the opportunity to request reconsideration of a decision terminating treatment.
§ 711.97. 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 all 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.
(7) Medication errors and drug reactions.
§ 711.98. Physical plant.
When the project is not physically located within a health care facility, it shall be site visited annually for the following requirements:
(1) Counseling areas.
(2) Office space.
(4) Fire escape/emergency exits.
(5) Fire extinguishers.
(6) General maintenance.
(7) Certificate of Occupancy from the Department of Labor and Industry or its equivalent.
(8) Compliance with applicable local ordinances and regulations.
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