N.Y. Comp. Codes R. & Regs. tit. 14 § 819.5

Current through Register Vol. 46, No. 50, December 11, 2024

Section 819.5 - Post admission procedures

(a) As soon as possible after admission, if not completed already, all programs must:

(1) offer viral hepatitis testing (testing may be done by referral);

(2) offer HIV testing (testing may not be conducted without a resident's written informed consent in accordance with public health law and may be done on site or by referral). Residents on a regimen of pre- or post- exposure prophylaxis must be permitted to continue the regimen until consultation with the prescribing professional occurs.

(3) Screen for co-occurring mental health conditions and behavioral health risks, including suicide risk, using validated screening instruments approved by the Office.

(4) If clinically appropriate, all programs must:

(i) conduct a blood-based tuberculosis test (testing may be done on site or by referral with results as soon as possible after testing); residents with a positive test result should be referred for further tuberculosis evaluation;

a. an intradermal PPD may be placed in those circumstances when a blood-based tuberculosis test cannot be performed unless the patient is known to be PPD positive;

b. PPD placement may done on site with medical staff interpreting the results or by referral with results as soon as possible after testing

(ii) offer testing for other sexually transmitted infections (testing may be done on site or by referral);

(iii) offer immunizations either on site or by referral;

(iv) offer pregnancy tests to persons of childbearing potential (testing may be done on site or by referral);

(v) provide or recommend any other tests the examining physician or other medical staff member working within their scope of practice deems necessary including, but not limited to, an ECG, a chest X-ray or other diagnostic tests.

(5) As soon as possible after testing, programs must review and discuss any blood, urine, and skin test results, ECG results, chest X-ray results, or other diagnostic test results where applicable with the residents.

(6) Any significant medical issues, including risk of transmissible infections, identified prior to or after admission must be addressed in the treatment/recovery plan and documented in the resident's record. Treatment/recovery plans must include provisions for the prevention, care, and treatment of HIV, viral hepatitis, tuberculosis, sexually transmitted infections, and other infectious diseases when present. If a resident chooses not to obtain such care and treatment, the provider must have the resident acknowledge in writing that such care and treatment were offered and declined.

(b) Comprehensive evaluation.

(1) The goal of the comprehensive evaluation shall be to obtain information from the resident and other sources, including family members and significant others if possible and where appropriate, that is necessary to develop an individualized, person-centered treatment/recovery plan.

(2) No later than fourteen days after admission, staff shall complete the resident's comprehensive evaluation which shall include a written report of findings and conclusions addressing, at a minimum, the resident's:

(i) identifying and emergency contact information;

(ii) the source of referral, date of commencing service, and name of the clinical staff member with primary responsibility for the resident;

(iii) both recent and history of substance use;

(iv) substance use disorder treatment history;

(v) comprehensive psychosocial history, including, but not limited to the following:

(a) legal history;

(b) transmissible infection risk assessment (HIV, tuberculosis, viral hepatitis, sexually transmitted infections, and other transmissible infections);

(c) an assessment of the resident's individual, social and educational strengths and limitations, including, but not limited to, the resident's literacy level, daily living skills and use of leisure time;

(d) the resident's current medical conditions, current mental health conditions, past medical history, past mental health history, and an assessment of the resident's risk of harming self or others.

(3) The comprehensive evaluation must include diagnoses, including substance-related, medical, and psychiatric diagnoses in official nomenclature with associated diagnostic codes in the most recent version of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

(4) The comprehensive evaluation shall bear the names of the clinical staff members who evaluated the resident and must be signed (physically or electronically) and dated by the qualified health professional responsible for the evaluation.

(c) Medical history and physical examination. Providers shall make every effort to execute appropriate consents to obtain and share medical information with the resident's other medical providers as appropriate.

(1) Residents who do not have an available medical history and have not had a physical examination performed within the last 12 months prior to admission must have a medical history recorded, and a physical examination performed and documented in the resident's record by a physician, physician assistant, or a nurse practitioner working within their scope of practice within forty five days after admission. The physical examination may include but shall not be limited to the investigation of, and if appropriate, screenings for infectious diseases; pulmonary, cardiac or gastrointestinal abnormalities; and physical, neurological, and/or psychological limitations or disabilities which may require special services or attention during treatment. The physical examination shall also include the following laboratory tests:

(i) complete blood count and differential;

(ii) routine and microscopic urinalysis;

(iii) if medically or clinically indicated, urine toxicology test;

(iv) pregnancy test for persons of childbearing potential;

(v) blood-based tuberculosis test

(a) an intradermal PPD may be placed in those circumstances when a blood-based tuberculosis test cannot be performed, with the results interpreted by the medical staff working within the scope of their practice unless the resident is known to be PPD positive;

(vi) any other tests the examining physician or other medical staff members working within their scope of practice deem to be necessary, including, but not limited to, an ECG, a chest X-ray, or other diagnostic tests.

(2) If the resident has a medical history available and has had a physical examination performed within 12 months prior to admission, or if the resident has been admitted directly to the residential service from another substance use disorder service authorized by the Office, the existing medical history and physical examination documentation may be used to comply with the requirements of this Part, provided that such documentation has been reviewed and determined to be current and accurate. Notwithstanding the forgoing, the following shall be offered regardless of a documented history within the previous twelve months: HIV and viral hepatitis testing.

(i) a focused medical history shall be taken and/or physical examination shall be performed and/or laboratory tests and other diagnostic tests shall be ordered if the examining physician, physician assistant, or nurse practitioner working within the scope of their practice determine that the elements of the existing medical history and/or physical examination and/or results of laboratory and other diagnostic tests require reevaluation based on the clinical judgment of the examining physician or other medical staff;

(ii) a focused medical history shall be taken and/or physical examination shall be performed and/or laboratory and other diagnostic tests shall be ordered if the resident has a physical complaint that was not addressed in the existing medical history and/or physical examination, and/or the resident has a new complaint that developed since the existing medical history was taken and/or existing physical examination was performed.

(3) Resident records shall include a summary of the medical history and the results of the physical examination, laboratory tests, and other diagnostic tests and shall also demonstrate that appropriate medical care, including mental health care, is recommended to any resident who needs such care.

(d) After the comprehensive evaluation is completed, a resident shall be retained in such treatment if the resident has a diagnosis of a substance use disorder in accordance with the most recent edition of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) and continues to meet the admission criteria required by this Part.

(e) If the comprehensive evaluation indicates that the resident needs services beyond the capacity of the residential service to provide either alone or in conjunction with another program, referral to appropriate services shall be made. Identification of such referrals and the results of those referrals to identified program(s) shall be documented in the resident record.

(f) If a resident is referred directly to the residential service from another service certified by the Office, or is readmitted to the same service within sixty (60) days of discharge, the existing level of care determination and comprehensive evaluation may be used, provided that the documentation has been reviewed and, if necessary, updated within fourteen (14) days of transfer.

(g) Treatment/recovery plan. A person-centered, initial treatment/recovery plan addressing the resident's individual needs must be developed within three days of admission, or readmission, to the substance use disorder residential service. The treatment/recovery plan shall be developed by the clinical staff member with primary responsibility for the resident ("the responsible clinical staff member") in collaboration with the resident and anyone identified by the resident as supportive of their recovery goals. This initial treatment/recovery plan must contain a statement which documents that the resident meets admission criteria for this level of care, identifies the assignment of a named clinical staff member with the responsibility to provide orientation to the resident, and includes a preliminary schedule of activities, therapies and interventions.

(h) A treatment/recovery plan, based on the admitting evaluation, shall be prepared within thirty days of development of the initial treatment/recovery plan to meet the identified needs of the resident, and shall take into account cultural and social factors as well as the particular characteristics, conditions and circumstances of each resident. For residents moving directly from one substance use disorder service to another, the existing treatment/recovery plan may be used if there is documentation that it has been reviewed and, if necessary, updated to reflect the resident's goals as appropriate.

(i) The treatment/recovery plan shall:

(1) be developed by the responsible clinical staff member(s) in collaboration with the resident and anyone identified by the resident as supportive of their recovery goals;

(2) be based on the admitting evaluations specified above and any additional evaluation(s) the resident has received or is determined to be required;

(3) specify measurable treatment goals for each problem identified;

(4) specify the objectives that shall be used to measure progress toward attainment of goals;

(5) include schedules for the provision of all services prescribed; where a service is to be provided by any other service or facility offsite, the treatment/recovery plan must contain a description of the nature of the service, a record that referral for such service has been made, the results of the referral, and procedures for ongoing care coordination and discharge planning;

(6) identify the responsible clinical staff for coordinating and managing the resident's treatment, who shall approve and sign (physically or electronically) such;

(7) reference any significant medical and mental health issues, including applicable medications, identified as part of the medical assessment process;

(8) include each diagnosis for which the resident is being treated;

(9) be reviewed, approved, signed (physically or electronically), and dated by the supervisor of the responsible clinical staff member within seven (7) days after the finalization of the treatment/recovery plan. If the supervisor of the responsible clinical staff member is not a qualified health professional, another qualified health professional must be designated to sign (physically or electronically) the plan; and

(10) Pregnancies. Treatment/recovery plans must include provisions for prenatal care for all residents who are pregnant or become pregnant. If a pregnant resident chooses not to obtain such care, the provider must have the resident acknowledge in writing that prenatal care was offered, recommended, and declined. The program should offer to develop a plan of safe care with the resident and anyone identified by the resident, and such offer should be noted in the resident's record.

(11) Transmissible infections. Treatment/recovery plans must include provisions for the prevention, care, and treatment of HIV, viral hepatitis, tuberculosis, and/or sexually transmitted infections when present. If a resident chooses not to obtain such care and treatment, the provider must have the resident acknowledge that such care and treatment were offered, recommended, and declined.

(j) Treatment according to the treatment/recovery plan. The responsible clinical staff member shall ensure that the treatment/recovery plan is included in the resident record and that all treatment is provided in accordance with the treatment/recovery plan.

(1) If, during the course of treatment, revisions to the treatment/recovery plan are determined to be clinically necessary, a multidisciplinary case conference will be held with the resident to determine what revisions to the treatment plan are needed to help the resident achieve their goals.

(k) Progress notes.

(1) Progress notes shall be written, signed (physically or electronically) and dated by the responsible clinical staff member or another clinical staff member familiar with the resident's care no less often than once every two weeks. Progress towards all treatment/recovery plan goals that are made during the two-week period must be documented in the applicable progress note.

(2) Progress notes shall provide a chronology of the resident's progress related to the goals established in the treatment/recovery plan and be sufficient to delineate the course and results of treatment. The progress notes shall indicate the resident's participation in all significant services that are provided.

(l) Resident deaths. If a resident dies while in active treatment any known details must be documented in the resident record.

(m) Discharge planning. Discharge planning shall begin upon admission and shall be considered part of the treatment/recovery planning process. The plan for discharge shall be developed by the responsible clinical staff member in collaboration with the resident and anyone the resident identifies as supportive of their recovery. If the resident is a minor, the discharge plan must also be developed in consultation with their parent or guardian, unless the minor is being treated without parental consent as authorized by Section 22.11 of the Mental Hygiene Law. Information pertaining to testing and treatment of sexually transmitted infections including HIV cannot be shared with the minor resident's parent or guardian without the resident's consent in accordance with applicable laws and regulations.

(1) A resident discharged from the program must be discharged for a documented reason. Residents discharged involuntarily must be discharged consistent with Part 815 of this Title.

(2) The discharge plan shall be based on the resident's self-reported confidence in their recovery and following an individualized recovery support plan, an assessment of the resident's home environment, suitability of housing, vocational/educational/employment status, and relationships with significant others to establish the level of social resources available to the resident and the need for services to significant others. In accordance with guidance and standards issued by the Office, the discharge plan shall include but not be limited to:

(i) identification of continuing substance use disorder services, medical and mental health services, rehabilitation, recovery, wellness, and vocational, educational and employment services the resident will need after discharge;

(ii) identification of specific providers of these needed services; and

(iii) specific referrals with appointment dates and times for any needed services;

(iv) identification of the type of residence that the resident will need after discharge;

(v) prescriptions and/or other arrangements to ensure access to medications including medications for addiction treatment for substance use disorders; and

(vi) overdose prevention education, naloxone education and training, and a naloxone kit or prescription for the resident and their family/significant other(s).

(n) No resident shall be discharged without a discharge plan that has been reviewed and approved by the responsible clinical staff member and the clinical supervisor or designee prior to the discharge of the resident. The portion of the discharge plan that includes referrals for continuing care shall be given to the resident upon discharge. Documentation detailing why a discharge plan was not provided to the resident prior to discharge must be placed in the resident record if the resident did not receive the plan.

(o) Discharge criteria. A resident shall be appropriate for discharge from the residential service and shall be discharged when they meet one or more of the following criteria:

(1) the resident has accomplished the goals and objectives which were identified in the treatment/recovery plan;

(2) the resident declines further care;

(3) the resident has been referred to other treatment that meets their individual needs and cannot be provided in conjunction with the residential service;

(4) the resident has been removed from the service by the criminal justice system or other legal process;

(5) the resident has received maximum benefit from the service; and/or

(6) the resident does not adhere to the written behavioral standards of the facility, provided that the resident is offered a referral and connection to another treatment program. A discharge for behavioral reasons with an offer of a referral and connection to another treatment program shall occur only after the program has utilized interventions to help the resident manage their behavior in a manner consistent with the written behavioral standards of the facility, and in accordance with guidance from the Office.

(p) A discharge summary which includes the course and results of treatment must be prepared and included in each resident's record within thirty (30) days of discharge.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 819.5

Amended New York State Register September 14, 2022/Volume XLIV, Issue 37, eff. 10/1/2022