Subchapter I. STANDARDS FOR OUTPATIENT ACTIVITIES
Sec.
709.91. Intake and admission.
709.92. Treatment and rehabilitation services.
709.93. Client records.
709.94. Project management services.
Cross References 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).
§ 709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, 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 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.
§ 709.92. 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 60 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.
§ 709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client’s 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) Individual treatment and rehabilitation plan.
(7) Client-related correspondence.
(8) Case consultation notes.
(9) Aftercare plan, if applicable.
(10) Discharge summary.
(11) Follow-up information.
(b) The project shall develop and maintain client records on standardized project client record forms.
§ 709.94. 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 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.
(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).
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