Subchapter E. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIES—SHORT-TERM DETOXIFICATION
Sec.
711.61. Intake and admission.
711.62. Client records.
711.63. Project management services.
711.64. Uniform Data Collection System.
711.65. Notification of termination.
711.66. Medication control.
711.67. Physical plant.
Cross References This subchapter cited in 31 Pa. Code § 89.621 (relating to inpatient detoxification services).
§ 711.61. 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 other than initial medical care shall be performed at a time when the immediate physiological effects of drug and alcohol abuse have subsided.
(c) 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.
§ 711.62. 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) Drug and alcohol support plan.
(3) Progress notes.
(4) Record of services provided.
(5) Aftercare plans, if applicable.
(6) Follow-up information.
(7) Verification that work done by the client at the project is an integral part of the drug and alcohol support 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.
(c) Confidentiality.
(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, 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.
§ 711.63. 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 include, but are not limited to, the following:
(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 area.
(5) Personal hygiene for those in food preparation areas.
(6) Special dietary needs.
(b) There shall be a written plan that delineates specific service planning and counseling approaches used to promote patient interest in participating in necessary treatment, following the detoxification process.
(c) 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.
(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) The project staff shall obtain written letters of agreement or understanding with primary referral sources.
§ 711.64. Uniform Data Collection System.
(a) If a project utilized Department funds, it shall comply with the Department’s UDCS.
(b) A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.
§ 711.65. 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.
§ 711.66. 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.
(6) Inventories.
(7) Medication errors and drug reactions.
§ 711.67. [Reserved].
Source The provisions of this § 711.67 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210295).
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