N.H. Admin. Code § He-A 304.23

Current through Register No. 2, January 9, 2025

Section He-A 304.23 - Required Medical and Clinical Services

(a) The OTP shall have a designated medical director who shall be responsible for all medical services.

(b) The medical director shall ensure that, for every client:

(1) Treatment plans are prepared and updated pursuant to (f) -(i) below;

(2) The client's need for methadone/buprenorphine maintenance is evaluated at least every 6 months;

(3) Any controlled substances prescribed for a client are clinically justified and documented in accordance with all applicable regulations, statutes, and rules; and

(4) A determination is made regarding the client's need for any other specialized services, such as treatment for other substance use disorders, medical services, or psychiatric services, and any such conditions are identified and treated or a referral is made to an appropriate service provider.

(c) Upon a client's admission, the OTP shall conduct a client orientation, either individually or by group, to include the following:

(1) Rules, policies, and procedures of the OTP and facility;

(2) Obtaining consent, which is compliant with 42 CFR Part 2, relative to the OTP reporting to law enforcement that a client may be operating a motor vehicle while impaired in as described in He-A 304.14(e) ;

(3) Requirements for successfully completing the program;

(4) The administrative discharge policy and the grounds for administrative discharge;

(5) All applicable laws regarding confidentiality, including the limits of confidentiality and mandatory reporting requirements; and

(6) Requiring the client to sign a receipt that the orientation was conducted.

(d) Pregnancy testing shall be conducted as follows:

(1) Unless contraindicated by sexual orientation or physiological factors, a OTP shall test monthly for pregnancy any female client of childbearing age who is using methadone/buprenorphine;

(2) If pregnancy is confirmed, the OTP shall:

a. Refer the client for health care for her pregnancy; and

b. Coordinate her treatment with all health care providers involved in her prenatal care; and

(3) If a pregnant client refuses to obtain primary care for her pregnancy, staff shall ask the client to sign a statement indicating she has refused such care, or shall document the client's refusal of care and refusal to sign.

(e) A licensed counselor or unlicensed counselor under the supervision of a licensed supervisor shall develop and maintain a written treatment plan for each client in accordance with SAMHSA's "TAP 21: Addiction Counseling Competencies" (2015 edition), available as noted in Appendix A, which addresses all ASAM Criteria (2013), available as noted in Appendix A, domains.

(f) Treatment plans shall be developed in the first session following the evaluation.

(g) Individual treatment plans shall contain, at a minimum, the following elements:

(1) Goals, objectives, and interventions written in terms that are specific, measurable, attainable, realistic, and timely.

(2) Identifies the recipient's clinical needs, treatment goals, and objectives;

(3) Identifies the client's strengths and resources for achieving goals and objectives in (1) and (2) above;

(4) Defines the strategy for providing services to meet those needs, goals, and objectives;

(5) Identifies referral to outside providers for the purpose of achieving a specific goal or objective when the service cannot be delivered by the OTP;

(6) Provides the criteria for terminating specific interventions;

(7) Includes specification and description of the indicators to be used to assess the individual's progress;

(8) Documentation of participation by the client in the treatment planning process or the reason why the client did not participate; and

(9) Signatures of the client and the counselor agreeing to the treatment plan, or if applicable, documentation of the client's refusal to sign the treatment plan.

(h) Treatment plans shall be reviewed no less frequently than every 4 sessions or every 4 weeks, whichever is less frequent and updated based on any changes in any of the ASAM Criteria (2013) domains, available as noted in Appendix A.

(i) Treatment plan updates shall include:

(1) Documentation of the degree to which the client is meeting treatment plan goals and objectives;

(2) Modification of existing goals or addition of new goals based on changes in the client's functioning relative to ASAM Criteria (2013), available as noted in Appendix A, domains and treatment goals and objectives;

(3) Documentation that the ASAM Criteria (2013), available as noted in Appendix A, transfer, discharge, and continuing care criteria were reviewed with the client in each of the ASAM Criteria (2013), available as noted in Appendix A, domains and that the client, counselor and licensed practitioner have jointly concluded that:

a. The client requires continued treatment at the current level of care; or

b. The client requires treatment at a higher or lower level of care and the updated treatment plan reflects transition to that level of care; and

(4) The signature of the client and the counselor agreeing to the updated treatment plan, or if applicable, documentation of the client's refusal to sign the treatment plan.

(j) In addition to the individualized treatment planning in (d) above, all OTPs shall provide client education on:

(1) Substance use disorders;

(2) Relapse prevention;

(3) Infectious diseases associated with injection drug use, including but not limited to, HIV, hepatitis, and TB;

(4) Sexually transmitted diseases;

(5) Emotional, physical, and sexual abuse;

(6) Nicotine use disorder and cessation options;

(7) The impact of drug and alcohol use during pregnancy, risks to the fetus, and the importance of informing medical practitioners of drug and alcohol use during pregnancy;

(8) Education around neonatal abstinence syndrome (NAS) for pregnant women to include significant others and/or care givers as appropriate;

(9) Working with family or significant others;

(10) Living and coping skills;

(11) Medication and drug education;

(12) Dealing with a positive drug screen;

(13) Education, vocational training, employment, or any combination thereof; and

(14) Education about acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) .

(k) Based on the client's treatment plan, methadone/buprenorphine maintenance treatment shall include medication and clinical services as detailed in Table 304.01.

(l) The OTP shall maintain the client with a dose adequate to alleviate all withdrawal symptoms;

(m) The OTP shall establish client dosing based on individual need, as detailed in the client's treatment plan; and

(n) The OTP shall provide flexible dosage tapering at the client's request.

(o) Upon a client's compliance with required treatment and counseling and the negative results for all drug screens conducted, the required number of hours of counseling shall be reduced and the allowed number of take-home doses shall be increased, in accordance with Table 304.01 below:

Table 304.1 Treatment, Counseling, and Take-Home Schedule

Consecutive Days in Compliance with He-A 304.24(o)	Required Hours of Counseling per Month	Allowed days supply of Take-Home Doses per Week
1-90	8	0
91-180	8	1
181-364	6	2
365-540	4	3
541-730	4	4
731-909	2	5
910+	1	6

(p) For clients who are required to engage in 8 hours of counseling per month, the OTP may reduce the number of hours by up to 4 hours if clinical staff determine that such a reduction will not result in an increased risk assessment in any of the ASAM Criteria (2013), available as noted in Appendix A, dimensions.

(q) An OTP shall not issue more than a 6-day supply of take-home doses to a client in one week.

(r) Required substance use disorder counseling shall be based on the client's individualized treatment plan and be consistent with ASAM Criteria (2013), available as noted in Appendix A, and SAMHSA's TIPS and TAPS standards, as applicable, and include, at a minimum:

(1) Any combination of individual, group, or family substance use disorder treatment services;

(2) Case management services, which may be substituted on an hour-for-hour basis for up to 25% of the required counseling hours; and

(3) Discussion between clinical staff and the client regarding the commencement of a methadone/buprenorphine discontinuance plan, with projected target dates for implementation, which may:

a. Be short-term or long-term in nature based on the client's need and preference; and

b. Include intermittent periods of methadone/buprenorphine maintenance between discontinuance attempts.

(s) If the licensed practitioner determines that split dosing is medically necessary, the OTP shall request a split-dose exception on-line, using the SAMHSA OTP Exception Request website at https://otp-extranet.samhsa.gov/login.aspx?ReturnUrl=%2f.

(t) Such requests shall include, as appropriate:

(1) OTP identification number;

(2) Patient identification number;

(3) OTP name;

(4) OTP contact information;

(5) Requestor information;

(6) Patient admission date;

(7) Patient's current dosage;

(8) Medication type;

(9) Patient's attendance schedule;

(10) Employment status;

(11) Nature of the change request;

(12) Start date of the requested change;

(13) End date of the requested change;

(14) Number of doses to be dispensed during the exception period;

(15) Justification for the change request;

(16) Regulatory compliance information; and

(17) Submitting physician information and dated signature.

(u) The OTP shall provide group education and counseling as follows:

(1) The OTP shall maintain an outline of each educational and group therapy session provided; and

(2) All group counseling sessions shall be limited to 12 clients or fewer per counselor.

(v) All client activities and services shall be documented in accordance with SAMHSA's "TAP 21: Addiction Counseling Competencies" (2015 edition), available as noted in Appendix A, and He-A 304.18.

N.H. Admin. Code § He-A 304.23

Derived From Volume XXXVIII Number 10, Filed March 8, 2018, Proposed by #12476, Effective 2/16/2018, Expires 2/16/2028.