6339.1 Diagnostic Assessment and Plan of Care services include two distinct actions:
(1) the assessment and diagnosis of the client, and(2) the development of the Plan of Care. A Diagnostic Assessment and Plan of Care Service may be (1) Comprehensive or (2) Ongoing.6339.2 The Diagnostic Assessment portion of this service includes the evaluation and ongoing collection of relevant information about a client to determine or confirm an SUD diagnosis and the appropriate LOC. The assessment shall serve as the basis for the formation of the Plan of Care, which establishes medical necessity and is designed to help the client achieve and sustain recovery. The assessment instrument shall incorporate ASAM criteria.
6339.3 All assessment services must include a Plan of Care, including the development of or an update to a Plan of Care and necessary referrals. Updates to the Plan of Care shall occur, at a minimum:
(a) Every one hundred and eighty (180) days for all clients in OTP and Level 1 programs;(b) Every sixty (60) days for clients in Level 2.1 programs;(c) Every thirty (30) days for clients in Level 2.5 programs;(d) Every ninety (90) days for clients in Level 3.1 or 3.3 programs;(e) Every twenty-eight (28) days for clients in Level 3.5 programs; and(f) Every five (5) days for clients in Level 3.7 programs.6339.4 Providers shall use a tool(s) approved by the Department for both the Diagnostic Assessment and Plan of Care.
6339.5 Diagnostic Assessment and Plan of Care services shall be provided in certified SUD treatment programs or community settings.
6339.6 The Plan of Care shall be person-centered and include the following elements:
(a) Overall broad, long-term goal statement(s) that captures the client's and/or family's short- and long-term goals for the future, ideally written in first-person language. This shall include the client's self- identified recovery goals;(b) List or statement of individual or family strengths that support goal(s) accomplishment. These include abilities, talents, accomplishments, and resources;(c) List or statement of barriers that pose obstacles to the client's and/or family's ability to accomplish the stated goal(s). These include symptoms, functional impairments, lack of resources, consequences of behavioral health issues, and other challenges;(d) Statement of objectives that identify the short-term client and/or family changes in behavior, function, or status that can help overcome the identified barriers and are building blocks toward the eventual accomplishment of the long-term goal(s). Objective statements describe outcomes that are measurable and include individualized target dates to be accomplished within the scope of the plan;(e) Intervention statements that describe the treatment and recovery services to be utilized to reduce or eliminate the barriers identified in the plan and support objective and eventual goal(s) accomplishment. Interventions are specific to each objective and the client's and/or family's stage of change. Intervention statements identify who will deliver the service, what will be delivered, when it will be delivered, and the purpose of the intervention. Natural support interventions should also be included in the plan and include those non-billable supports delivered by resources outside of the formal behavioral health service-delivery system. When appropriate and applicable, EBP shall be incorporated into the intervention statement;(f) Provide for the delivery of services in the least restrictive environment that is appropriate for the client;(g) The client or legal guardian's signature on the plan (if the client refuses to sign the Plan of Care, the Clinical Care Coordinator shall document the reason(s) in the Plan of Care); and(h) Signatures of all interdisciplinary team members participating in the development of the Plan of Care. A Plan of Care is valid when electronically signed and dated by an independently licensed clinician working within the scope of their license. (i) For individuals receiving only RSS services, their Plan of Care shall be signed by those Qualified Practitioners described in §6344.11.6339.7 For clients who are determined appropriate for an outpatient level of care (outpatient OTP, Level 1, Level 2.1, and Level 2.5) and who meet the eligibility requirements described in §§ 6301.4 or 6301.5, the outpatient provider delivering such services shall, as a part of the development or updating of the Plan of Care, comply with the requirements set forth in 22-A DCMR Chapter 37 regarding:
(a) Assessment of the client for interest in, potentially eligibility for, and referral to SUD Supported Employment services, and(b) Integration of Employment Specialists into the SUD provider's treatment team.6339.8 An Initial Assessment/Diagnostic and Plan of Care service ("Initial Assessment") is a behavioral health assessment that (1) identifies the client's need for SUD treatment, (2) determines the appropriate LOC of SUD treatment, and (3) initiates the course of treatment. The following provisions apply to an Initial Assessment:
(a) The provider shall use and complete an assessment tool approved by the Department that meets the ASAM biopsychosocial requirements. The assessment should result in identification of the necessary LOC and an appropriate provider referral, documented in the designated electronic record format.(b) The provider shall record any medications used by the client;(c) Staff must have an in-person encounter with the client to conduct the initial assessment;(d) Providers must obtain and document client's understanding and agreement, evidenced by the client's signature, for consent to treatment, assessment, provider choice, the client bill of rights, and release of information; and(e) A treatment provider will complete an Initial Assessment and refer the client to the appropriate LOC or treat the client 1) if the client is found appropriate for the LOC available at that provider, and 2) the client chooses to receive services at that provider.6339.9 A Comprehensive Diagnostic Assessment is a behavioral health assessment that collects, compiles, and integrates sufficiently detailed information to successfully guide level of care decisions, the place of care process, and the provision of services.
6339.10 Providers shall ensure appropriate staff (physician, PA, APRN, or RN) is available to assess clients for acute withdrawal symptoms and provide medical triage. Providers shall use a Department-approved assessment tool to determine the need for withdrawal management. Providers shall have infrastructure to conduct health testing and screening as appropriate, and storage for testing kits. If the provider does not have the infrastructure or medical personnel on their staff the provider shall enter into an affiliation agreement or contract with a medical provider for these services, or show the Department documentation that they are part of an integrated care setting that offers the services.
6339.11 The following provisions apply to the Comprehensive Diagnostic Assessment:
(a) When a client enters his or her first LOC within a treatment episode, the provider shall perform a Comprehensive Diagnostic Assessment to determine their treatment and recovery needs, unless a Comprehensive Diagnostic Assessment completed within the last sixty (60) days is available to the treating provider; in that case, an ongoing assessment may be completed. A Comprehensive Diagnostic Assessment consists of a biopsychosocial assessment and the development of a Plan of Care. ASAM biopsychosocial elements include, but are not limited to: (1) History of the presenting episode;(3) Developmental history;(4) Alcohol, tobacco, other drug use, addictive behavior history;(5) Personal/social history;(11) Mental status examination;(13) Formulation and diagnosis;(14) Survey of assets, vulnerabilities, and supports;(15) Treatment recommendations; and(16) Health screenings/testing including:(C) Tuberculosis (if referred for residential and detox); and(D) Pregnancy (If applicable).(b) A Comprehensive Diagnostic Assessment shall include the use of a Department-approved assessment tool and a detailed diagnostic formulation. The Comprehensive Diagnostic Assessment will document the client 's strengths, resources, mental status, identified problems, current symptoms as outlined in the DSM, and RSS needs. The Comprehensive Diagnostic Assessment will also confirm the client's scores on the ASAM criteria and confirm that the assigned LOC is most applicable to the client's needs. The diagnostic formulation shall include presenting symptoms for the previous twelve (12) months, including mental and physical health symptoms, degree of severity, functional status, and differential diagnosis. This information forms the basis for the development of the individualized person-centered Plan of Care as defined in § 6339.
(c) A Comprehensive Diagnostic Assessment must be performed in-person by an interdisciplinary team consisting of the client and at least one Qualified Practitioner allowed to diagnose in accordance with their license.(d) The approval of the Plan of Care is demonstrated by the electronic signature and date stamp of an independently licensed Qualified Practitioner. A completed Plan of Care is required to establish medical necessity.(e) A Comprehensive Diagnostic Assessment and Plan of Care must be completed within seven (7) calendar days of the client's admission to a provider. Providers at Level 3.7-MMIWM must complete a Comprehensive Diagnostic Assessment within forty-eight (48) hours of the client's admission, or prior to discharge or transfer to another LOC, whichever comes first.(f) Within twenty-four (24) hours of the client's admission at a new LOC, during the period prior to the completion of the Comprehensive Diagnostic Assessment, the provider shall review the client's prior Department-approved Diagnostic Assessment to assist with developing a Plan of Care.(g) The Plan of Care (valid for seven (7) calendar days) will validate treatment until the Comprehensive Diagnostic Assessment is completed. A Qualified Practitioner as listed in § 6339 shall develop the Plan of Care. A Comprehensive Diagnostic Assessment and Plan of Care shall include client understanding and agreement, documented by the client's signature, for consent to treatment, assessment, provider choice, client bill of rights, and release of information.6339.12 Ongoing Diagnostic Assessment and Plan of Care occurs at regularly scheduled intervals depending on the LOC. The following provisions apply to on going assessments:
(a) An Ongoing Diagnostic Assessment and Plan of Care, conducted using a tool(s) approved by the Department, provides a review of the client's strengths, resources, mental status, identified problems, and current symptoms as outlined in the most recent DSM.(b) An Ongoing Diagnostic Assessment will confirm the appropriateness of the existing diagnosis and revise the diagnosis, as warranted. The Ongoing Diagnostic Assessment will also revise the client's scores on all dimensions of the ASAM criteria, as appropriate, to determine if a change in LOC is needed and make recommendations for changes to the Plan of Care.(c) An Ongoing Diagnostic Assessment includes a review and update of the Plan of Care with the client to reflect the client 's progress, growth, and ongoing areas of need.(d) The Ongoing Diagnostic Assessment and Plan of Care is also used prior to a planned transfer to a different LOC and for discharge from a course of service.(e) The Ongoing Diagnostic Assessment can be used for a review and documentation of a client's physical and mental status for acute changes that require an immediate response, such as a determination of a need for immediate hospitalization.(f) The Clinical Care Coordinator shall determine the frequency of Ongoing Diagnostic Assessments and Plan of Care services.(g) An Ongoing Diagnostic Assessment and Plan of Care must be completed in-person with the client and at least one Qualified Practitioner with the license and capability to develop a diagnosis.(h) The Ongoing Diagnostic Assessment requires documentation of the assessment tools, updated diagnostic formulation, and the Plan of Care update. The diagnostic formulation shall include presenting symptoms since previous assessment (including mental and physical health symptoms), degree of severity, functional status, and differential diagnosis. The Plan of Care update shall address current progress toward goals for all problematic areas identified in the Diagnostic Assessment and adjust interventions and RSS as appropriate.6339.13 Qualified Practitioners of Diagnostic Assessment and Plan of Care who are permitted to screen, assess, and diagnose are:
6339.14Qualified Practitioners of Diagnostic Assessment and Plan of Care who are permitted to provide screening and assessment services, but who are not permitted to diagnose are:
(a) Psychology Associates;D.C. Mun. Regs. r. 22-A6339
Final Rulemaking published at 62 DCR 12056 (9/4/2015); amended by Final Rulemaking published at 67 DCR 11585 ( 10/9/2020); amended by Final Rulemaking published at 68 DCR 012400 (11/26/2021)