16 Del. Admin. Code § 6001-II-8.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 6001-II-8.0 - Standards Applicable to all Facilities and Programs

8.1 Clinical records

8.1.1 Maintenance of client records

8.1.1.1 Programs shall:

8.1.1.1.1 Maintain a record for each client that is

8.1.1.1.1.1 Accurate,

8.1.1.1.1.2 Legible and

8.1.1.1.1.3 Signed by the staff member who provided the service.

8.1.1.1.2 Maintain a standardized client record-keeping system, with client records that are uniform in format and content;

8.1.1.1.3 Establish and maintain a system that permits easy identification of and access to individual client records by authorized program staff;

8.1.1.1.4 Comply fully with the provisions of 42 U.S.C. § 290dd-2 and 42 CFR Part 2 and HIPAA 45 CFR parts 160 and 164;

8.1.1.1.5 Update each record within twenty-four (24) hours of delivery of a service unless otherwise specified in these regulations.

8.1.1.2 Any program that discontinues operations, or is merged with, or acquired by another program is responsible for ensuring compliance with the requirements of 42 CFR § 2.19, and HIPAA 45 CFR parts 160 and 164 whichever is applicable. The program shall document in writing to the Division:

8.1.1.2.1 How it will adhere to 42 CFR § 2.19 and HIPAA 45 CFR parts 160 and 164 at the time it notifies the Division of the program closure in accordance with § 4.10.5 of these regulations; and

8.1.1.2.2 How it will adhere to § 8.0 of these regulations.

8.1.2 Content of Client records

8.1.2.1 A record shall be established for each client upon admission and shall include:

8.1.2.1.1 A Consent to Treatment form signed by the client and, if the client is a minor, the client's parent or guardian, except as provided in 16Del.C.§ 2210(b).

8.1.2.1.2 An up-to-date face sheet including the client's:

8.1.2.1.2.1 Date of admission;

8.1.2.1.2.2 Name;

8.1.2.1.2.3 Address;

8.1.2.1.2.4 Telephone number;

8.1.2.1.2.5 Gender;

8.1.2.1.2.6 Date of birth;

8.1.2.1.2.7 The client's significant medical history documenting:

8.1.2.1.2.7.1 Current medical conditions;

8.1.2.1.2.7.2 Any medications the client is currently prescribed;

8.1.2.1.2.7.3 Any medications the client is currently taking;

8.1.2.1.2.7.4 Allergies,

8.1.2.1.2.8 The name and telephone number of the person to contact in an emergency;

8.1.2.1.2.9 An attached Consent to Release Information form permitting the program to make that contact;

8.1.2.1.2.10 Name, address and telephone number of most recent primary care provider.

8.1.2.1.3 Appropriate Consent to Release Information forms.

8.1.2.1.4 Documentation, signed by the client:

8.1.2.1.4.1 Acknowledging receipt of the notice of clients' rights;

8.1.2.1.4.2 Acknowledging his/her understanding of the agency's agreement with the confidentiality requirements of § 7.1.2.1.9;

8.1.2.1.4.3 Acknowledging receipt of the program's procedures when an emergency occurs outside of the program's hours of operation.

8.1.2.1.5 Copies of any laboratory reports and drug tests ordered by the program.

8.1.2.1.6 Informed consent regarding prescribed pharmacotherapy obtained from the client prior to delivery of the medication prescription.

8.1.2.1.7 Results of the client's diagnostic assessment, including the client's:

8.1.2.1.7.1 Mental health status;

8.1.2.1.7.2 Psychiatric history;

8.1.2.1.7.3 Medical history (including allergies);

8.1.2.1.7.4 Education;

8.1.2.1.7.5 Work history;

8.1.2.1.7.6 Criminal justice history;

8.1.2.1.7.7 Substance use history, including:

8.1.2.1.7.7.1 Types;

8.1.2.1.7.7.2 Quantity;

8.1.2.1.7.7.3 Route;

8.1.2.1.7.7.4 Frequency of substances used;

8.1.2.1.7.7.5 Age of first use;

8.1.2.1.7.7.6 Date of last use;

8.1.2.1.7.7.7 Duration and patterns of use, including:

8.1.2.1.7.7.7.1 Periods of abstinence;

8.1.2.1.7.8 Past supports and resources that were effective in previous recovery attempts;

8.1.2.1.7.9 Previous treatment episodes and type of discharge;

8.1.2.1.7.10 Reason(s) for seeking treatment;

8.1.2.1.7.11 Identification and evaluation of the client's needs;

8.1.2.1.7.12 History of other addictive disorders.

8.1.2.1.7.13 Family History including:

8.1.2.1.7.13.1 Psychiatric history;

8.1.2.1.7.13.2 Use of alcohol and other drugs by family members and significant others.

8.1.2.1.7.14 A diagnostic assessment summary of the client's status that addresses the client's:

8.1.2.1.7.14.1 strengths;

8.1.2.1.7.14.2 barriers to treatment; and

8.1.2.1.7.14.3 goals.

8.1.2.1.7.15 Indicates which what issues and areas of clinical concern are to be:

8.1.2.1.7.15.1 Treated;

8.1.2.1.7.15.2 Deferred; or

8.1.2.1.7.15.3 Referred.

8.1.2.1.7.16 Includes the client's:

8.1.2.1.7.16.1 Primary language;

8.1.2.1.7.16.2 Cultural background;

8.1.2.1.7.16.3 Attitudes toward alcohol and other drug use; and

8.1.2.1.7.16.4 Spiritual or religious beliefs.

8.1.2.1.7.17 The rationale for placement recommendations:

8.1.2.1.7.17.1 Signed by the Counselor completing the assessment;

8.1.2.1.7.17.2 Reviewed, as indicated by the signature of the clinical supervisor; and

8.1.2.1.7.17.3 Is completed prior to the development of the initial Recovery Plan.

8.1.2.1.7.18 Copies of all correspondence related to the client.

8.1.2.1.8 An individualized Recovery Plan, developed in partnership with the client, shall be completed no later than the time required in these regulations for the modality for which the program is licensed.

8.1.2.1.9 The recovery plan shall:

8.1.2.1.9.1 Identify the date the plan is to be effective;

8.1.2.1.9.2 Identify the client's:

8.1.2.1.9.2.1 Strengths;

8.1.2.1.9.2.2 Barriers to treatment; and

8.1.2.1.9.2.3 Goals.

8.1.2.1.9.3 Address the goals as derived from the assessment process:

8.1.2.1.9.3.1 To be treated.

8.1.2.1.9.3.2 Identify objectives that:

8.1.2.1.9.3.2.1 Address the goals;

8.1.2.1.9.3.2.2 Are specific;

8.1.2.1.9.3.2.3 Are measurable;

8.1.2.1.9.3.2.4 Are time limited; and

8.1.2.1.9.3.2.5 Specify the treatment regimen, including:

8.1.2.1.9.3.2.5.1 Which services and/or activities will be used to achieve each recovery plan objective;

8.1.2.1.9.3.2.5.2 The frequency of each service and/or activity to meet the goals/objectives;

8.1.2.1.9.3.2.5.3 Goals/objectives to be referred;

8.1.2.1.9.3.2.5.4 Goals/objectives to be deferred;

8.1.2.1.9.3.3 Be signed by:

8.1.2.1.9.3.3.1 The client;

8.1.2.1.9.3.3.2 The staff who developed the recovery plan; and

8.1.2.1.9.3.3.3 The clinical supervisor.

8.1.2.1.10 Periodic Recovery Plan Review/Revision

8.1.2.1.10.1 Recovery plans shall be reviewed and revised by the client and his/her counselor, and no less often than the intervals specified for the modality for which the program is licensed and shall address the issues remaining to be treated as derived from and recovery plan review.

8.1.2.1.11 Progress notes

8.1.2.1.11.1 Each contact made with or on behalf of the client in accordance with the interventions prescribed on the recovery plan shall be documented in the client file; and

8.1.2.1.11.1.1 Be written to include:

8.1.2.1.11.1.1.1 The type(s) of service provided;

8.1.2.1.11.1.1.2 The date of the service(s) provided;

8.1.2.1.11.1.1.3 The length of the service(s) provided; and

8.1.2.1.11.1.1.4 A description of the client's response to the session including:

8.1.2.1.11.1.1.4.1 Facts (a description of the service and/or activity and the client's participation in the service and/or activity);

8.1.2.1.11.1.1.4.2 Clinical impressions (the counselor 's assessment of the client's response or lack of response to the service and/or activity and the client's progress or lack of progress toward achieving the objectives prescribed in the recovery plan);

8.1.2.1.11.1.1.4.3 Plan for future sessions (anticipated implementation, by the counselor, of services and/or activities as prescribed in the recovery plan.)

8.1.2.1.12 Clinical Supervision

8.1.2.1.12.1 The clinical supervisor shall review each individual client record with the client's counselor as often as necessary, and in conjunction with recovery plan review and revision and no less often than at the intervals specified by each modality for which the program is licensed.

8.1.2.1.12.2 The clinical supervisor shall provide specific, written clinical recommendations on how to proceed with the case.

8.1.2.1.12.3 The clinical supervisor shall sign the recovery plan revision/review.

8.1.2.1.13 Discharge Plan

8.1.2.1.13.1 In anticipation of successful completion or planned interruption of a client's treatment, the treatment staff and client shall jointly develop a discharge plan.

8.1.2.1.14 Discharge Summary

8.1.2.1.14.1 For every client that is discharged, the program shall complete a discharge summary within seventy-two (72) hours of a planned discharge and within ninety-six (96) hours of an unplanned discharge.

8.1.2.1.14.2 The narrative discharge summary shall include the client's:

8.1.2.1.14.2.1 Name;

8.1.2.1.14.2.2 Discharge address;

8.1.2.1.14.2.3 Discharge telephone number;

8.1.2.1.14.2.4 Admission date;

8.1.2.1.14.2.5 Discharge date;

8.1.2.1.14.2.6 A summary of the client's progress toward treatment plan objectives;

8.1.2.1.14.2.7 A summary of the client's participation in treatment;

8.1.2.1.14.2.8 The reasons for discharge;

8.1.2.1.14.2.9 Any unresolved issues;

8.1.2.1.14.2.10 Recommendations regarding the need for additional treatment services.

8.1.2.1.14.3 When the discharge is planned, the discharge summary shall be signed by:

8.1.2.1.14.3.1 The client

8.1.2.1.14.3.2 The counselor, and

8.1.2.1.14.3.3 The clinical supervisor.

8.1.3 Programs shall provide a list of referral sources for the client's various needs when the agency is unable to meet the client's needs internally. The agency shall be responsible for assisting the client in enrolling in services at other agencies.

8.1.4 Programs shall provide a minimum of twelve (12) months of records up until and including the expiration date of the current license for the purposes of licensure audit. Programs shall develop a policy that clearly outlines timelines for record retention and storage for all records beyond the required audit period.

16 Del. Admin. Code § 6001-II-8.0

14 DE Reg. 471 (11/01/10)