N.J. Admin. Code § 10:161B-11.6

Current through Register Vol. 56, No. 8, April 15, 2024

Section 10:161B-11.6 - Admissions and assessment

(a) In addition to meeting the eligibility criteria for admission, a client admitted to an opioid treatment program shall receive a biopsychosocial assessment in accordance with 10:161B-9.1(a).

(b) Drug screening shall be analyzed, at a minimum, for opioids, methadone, cocaine, amphetamines, and benzodiazepines, and, as appropriate, for drugs of choice as evidenced in evaluation and/or intake assessment. Screening for alcohol, marijuana and other drugs shall be conducted based on individual and/or community drug use patterns in accordance with program policy established by the multidisciplinary team. Positive drug screens for other substances shall be documented in the client's case record and an appropriate clinical intervention will occur.

(c) An opioid treatment program shall conduct a complete physical examination, a medical history including drug use and current medications, treatment history and personal history before dispensing or administering medication. A program physician or other licensed independent practitioner authorized under New Jersey statutes shall conduct a complete physical examination at admission and shall include testing for the following:

1. Serological test for syphilis and testing for other sexually transmitted diseases as medically indicated;

2. Mantoux tuberculin skin test at admission and annually thereafter and chest x-ray if medically indicated. Testing shall be provided in accordance with the Tuberculosis Surveillance Procedures for Substance Abuse Treatment Facilities (SATFs), incorporated herein as chapter Appendix A;

3. Urine or other approved screening to identify drug use;

4. Routine and microscopic urinalysis;

5. Complete Blood Count (CBC);

6. SMA 12 or comparable screening;

7. Pregnancy test for women;

8. Screening for Hepatitis C and Hepatitis B surface antigen and antibody is highly recommended but not required;

9. All clients shall receive HIV pre-test counseling, and shall be offered HIV testing onsite or at a DOH/HIV, STD, and TB Services approved rapid HIV testing clinic, with referral documented in the client file; however, a client has the right to refuse HIV testing. Documentation of refusal must be contained in the client file; and

10. Mental health status evaluation to include previous psychiatric admissions, and a history of suicidal ideation, outpatient psychiatric treatment, psychotropic medications and, when clinically indicated, an assessment by a psychiatrist or other licensed clinician of clients diagnosed and identified as having a co-occurring mental health disorder.

(d) If the client submits documentation of the testing in (c) above performed within 30 days of admission, those tests need not be repeated with the exception of the drug screening and pregnancy testing.

(e) Clients re-entering an opioid treatment program after discharge shall be examined by the physician, screened for drugs and pregnancy, tested for tuberculosis (if it has been 12 or more months since the previous test), and offered HIV counseling and testing.

(f) The client assessment shall include information on the client's educational and vocational needs. Unemployed persons and others determined to be in need of educational and/or vocational assistance shall be provided services in the opioid treatment program, or shall be referred to appropriate resources within the community. Such referrals shall be documented in the client record and addressed in the treatment plan.

(g) Clients shall receive education and counseling regarding the behavioral risk factors for transmission of HIV and hepatitis B and C, screening tests and available treatment.

(h) If the opioid treatment program does not provide primary medical care services to its clients including prenatal care, it shall ensure that appropriate referrals are made for prenatal care, other medical and mental health services. This shall be based on findings of the physical examination or as identified during the course of maintenance treatment. Documentation of referrals, follow up, and coordination of care shall be contained in the client record.

N.J. Admin. Code § 10:161B-11.6

Amended by 48 N.J.R. 2791(a), effective 12/19/2016