Rule 111-8-53-.13 - Individual Treatment PlanA program must develop a preliminary individual treatment plan for each patient within 10 days of admission, which includes an initial treatment recommendation. A complete individual treatment plan for each patient must be developed within 30 days of admission. Patients must be involved in the development of their treatment plans. Treatment plans must document a consistent pattern of substance abuse treatment services and medical care appropriate to individual patient needs and must meet the requirements of 42 C.F.R. § 8.12(f)(4).
(a) Medical care, including referral for necessary medical service, and evaluation and follow-up of patient complaints must be compatible with current and accepted standards of medical practice. All patients must receive a physical examination by the medical director, the program physician, or an appropriately licensed and qualified member of the medical staff at least annually. All other medical procedures performed at the time of admission must be reviewed by the medical staff on an annual basis, and all clinically indicated tests must be repeated. The medical director or program physician shall evaluate the results of this annual medical examination and review of patient medical records and document such evaluation in each patient's record.(b) In recognition of the varied medical needs of patients, the case history and individual treatment plans must be reviewed at least every 90 days for patients in treatment less than one year and at least annually for patients in treatment more that one year. This review will be conducted by the medical director or program physician along with the primary counselor and other appropriate members of the treatment team for general quality controls and evaluation of the appropriateness of continuing the form of treatment on an ongoing basis. This review must also include an assessment of the current dosage and schedule and the rehabilitative progress of the patient, as part of determination of whether additional medical services are indicated. If such review results in a determination that additional or different medical services are indicated, the program must ensure that such services are made available to the patient and appropriate referrals for additional care are made.(c) When the program physician prescribes other controlled substances to patients in the program, the program physician shall ensure that such prescriptions are in accordance with all applicable statutes and regulation and with current and accepted standards of medical practice. Such prescriptions shall not be issued to any patient unless the medical director, the program physician, or a member of the medical staff first sees the patient and assesses the patient's potential for abuse of such medications.(d) As part of the rehabilitative services provided by the program, each patient must be provided with individual or group counseling appropriate to his or her needs. The frequency and duration of counseling provided to patients must be determined by appropriate program staff and be consistent with the individual treatment plan. Individual treatment plans must indicate a specific level of counseling services needed by the patient as part of the rehabilitative process.(e) All patients shall receive HIV risk reduction education appropriate to their needs.(f) When appropriate, each patient must be enrolled in an education program, or be engaged in a vocational activity (vocational evaluation, education, or skill training), or make documented efforts to seek gainful employment. Deviations from compliance with these requirements must be explained in the patient's record. Each program shall take steps to ensure that a comprehensive range of rehabilitative services, including vocational, educational, legal, mental health, alcoholism, and social services are made available to patients who demonstrate a need for such services. The program can fulfill such responsibility by providing support services directly or by appropriate referral. Support services recommended and utilized must be documented in the patient record.(g) All programs will develop and implement policies for matching patient needs to treatment and providing treatment in accordance with current and accepted standards of medical practice. These policies shall include treatment phasing, in which the intensity of medical, counseling, and rehabilitative services provided to a patient varies depending upon the patient's phase of treatment. Phases of treatment may include intensive stabilization for new patients and those in need of acute care, graduated rehabilitation phases, and medical maintenance or appropriate treatment-tapering phases for long-term stable patients.Ga. Comp. R. & Regs. R. 111-8-53-.13
O.C.G.A. §§ 26-5-2et seq., 31-2-5, 31-2-7.
Original Rule entitled "Individual Treatment Plan" adopted. F. Sep. 9, 2013; eff. Sept. 29, 2013.Amended: F. Feb. 15, 2018; eff. Mar. 7, 2018.