N.Y. Comp. Codes R. & Regs. tit. 14 § 822.8

Current through Register Vol. 46, No. 45, November 2, 2024

Section 822.8 - Patient Records/Treatment Planning

(a) General requirements for all patient records. All programs must maintain a patient record (either electronic or paper) for each patient who receives services. The patient record must demonstrate a chronological pattern of delivered medical and treatment services consistent with the patient's prior treatment history, if any, and the patient's evolving treatment/recovery plan, updated regularly through progress notes. The patient record shall also include:

(1) the source of referral, if applicable;

(2) a notation that, prior to the first treatment visit, the patient received a copy of the program's rules and regulations, including patient's rights (Part 815) and a summary of the federal confidentiality requirements, that such rules and regulations were discussed with the patient, including their ability to designate individuals to be notified in case of an emergency and that the patient indicated he/she understood them;

(3) any clinical or non-clinical documentation or determination applicable to the delivery of medical and treatment services for a patient and/or supporting the patient's evolving treatment/recovery plan;

(4) the individual treatment/recovery plan and all reviews and updates thereto through progress notes;

(5) signed releases of consent for information;

(6) documentation of services in accordance with this Part;

(7) documentation of level of care determinations using the OASAS level of care protocol for admission and level of care transition;

(8) transition planning, including medication list, circumstances/reason, and referrals made;

(9) if the patient is a minor being treated without parental consent, documentation establishing that the provisions of Mental Hygiene Law section 22.11 have been met.

(10) information and documentation required in screening and admission;

(11) all lab results;

(12) current approved medication doses and justification for any changes; and

(13) include an order sheet that is displayed in the patient record and signed (physical or electronic signature) by any medical professional licensed under the appropriate state law authorizing such change and noting the date for each approved medication order and dose change.

(b) Admission requirements applicable to all programs:

(1) Diagnosis.

(i) Unless otherwise authorized, the program must document that the individual is determined to have a substance use disorder based on the criteria in the most recent version of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

(ii) For a significant other, the program must document that the individual is determined to have a diagnosis consistent with the presenting concerns related to a close relationship with someone who has a substance use disorder.

(2) If an individual has been referred by an Office approved Driving While Intoxicated (DWI) provider/practitioner, any assessment created by such provider which meets the requirements of this section may be used to admit the patient.

(3) Documentation of admission must:

(i) include the level of care determination;

(ii) include an assessment, initial services and diagnosis that form the basis of the treatment/recovery plan;

(iii) be made by a clinical staff member who is a qualified health professional and must be documented by the dated signature (physical or electronic) of the qualified health professional working within their scope of practice and include the basis for admitting the patient; and

(iv) be approved by the dated signature (physical electronic) of a physician, physician's assistant, nurse practitioner, licensed psychologist, or licensed clinical social worker.

(4) Patients being admitted to an OTP must be documented to have a minimum 12-month opioid use disorder (OUD) accompanied by a physical evaluation. A comprehensive physical examination must be completed within fourteen days, or otherwise in accordance with federal rules.

(5) If the presenting individual is determined to be inappropriate for admission to the program, a referral and connection to a more appropriate service must be made, unless the individual is already receiving substance use disorder services from another provider. Individuals deemed ineligible for admission must be informed of the reason.

(6) No individual that meets level of care criteria may be denied admission to a program consistent with the provisions of Part 815 of this Title.

(7) All prospective patients must be informed that admission to a program is on a voluntary basis and a prospective patient is free to discharge themselves from the service at any time. For prospective patients under an external mandate, the potential consequences for premature discharge must be explained, including that the external mandate does not alter the voluntary nature of admission, continued treatment, and toxicology screening.

(8) A significant other may be admitted to a program regardless of whether the individual with whom they are associated is in treatment. A significant other is not appropriate for admission to an outpatient rehabilitation service.

(c) Post-admission.

(1) As soon as possible after admission, if not already complete, every patient must be:

(i) offered viral hepatitis testing; testing may be done on site or by referral;

(ii) offered HIV testing; testing must be conducted with patient consent in accordance with public health law and may be done on site or by referral; individuals on a regimen of pre- or post-exposure prophylaxis, must be permitted to continue the regimen until consultation with the prescribing professional occurs;

(iii) screened for co-occurring mental health conditions and behavioral health risk including suicide risk using validated screening instruments approved by the Office.

(2) If clinically indicated, all programs must:

(i) conduct an intradermal skin or blood-based Tuberculosis test; testing may be done on site or by referral with results as soon as possible after testing; for patients with a positive test result, refer the patient for further tuberculosis evaluation.

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

(iii) provide or recommend any other tests the examining physician or other medical staff member deems to be necessary including, but not limited to, an EKG, a chest X-ray, or a pregnancy test.

(3) As soon as possible after testing programs must explain or ensure that the provider has explained, any blood and skin test results to the patient.

(4) For those patients who have not had a physical examination within one year prior to admission, each such patient must either be assessed by a member of the medical staff to ascertain the need for a physical examination or referred for a physical examination. For those patients who have had a physical examination within one year prior to admission, or for those patients being admitted directly to the outpatient program 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 subdivision, provided such documentation has been reviewed by a medical staff member and determined to be current. Notwithstanding the foregoing, HIV and viral hepatitis testing shall be offered regardless of a documented history within the previous twelve months. OTPs are exempt from this requirement but must provide physical examinations in accordance with federal rules.

(d) Additional admission requirements for outpatient rehabilitation services. In addition to the requirements of paragraph (a) of this section, an individual must also meet the criteria in Section 822.10 of this Part to be admitted to an outpatient rehabilitation service.

(e) Additional admission requirements for OTPs.

(1) The decision to admit a prospective patient for treatment is finalized on the date of administration or prescription of the initial approved medication dose after satisfaction of all applicable requirements of this Part. Prospective patients with a chronic immune deficiency or prospective patients who are pregnant and have a current opioid or past opioid dependency must be screened and admitted on a priority basis. No person under the age of 16 may be admitted without the prior approval of the Office. The following requirements must be met for an individual to be admitted:

(2) In order to administer the first medication dose, a patient must have an in-person evaluation, including a physical evaluation, to determine that they have had a physiological dependence on opioids for at least the previous 12-month period, and must diagnose and document such, provided however:

(i) a prospective patient may be admitted who voluntarily completed treatment in another program without confirming current opioid dependence if the program confirms that the:

(a) voluntary completion of treatment occurred within the previous 24 months; and

(b) previous treatment lasted at least 6 months;

(ii) a prospective patient who is less than 18 years of age may be admitted if such patient has had at least two prior treatment episodes within a 12-month period and a dependence on opioids;

(iii) a prospective patient who resided in a correctional or chronic care facility for at least one month, if assessed within 6 months after release or discharge, may be admitted if the prospective patient would have been eligible for admission prior to residing in such facility.

(3) A physician, or other practitioner with federal approval, must ensure that prior to first dose, the prospective patient is provided and signs (physical or electronic signature) an informed written consent to participate in an opioid treatment program, which shall include notice of the risks and benefits of a prescribed medicine.

(4) Each OTP must issue a photo-identification card to each patient within two weeks after admission; patients may carry the identification or, at the patient's option, have the identification maintained at the program.

(f) Readmissions to OTPs. Programs need not repeat admission procedures for any patient who is being re-admitted within three (3) months of discharge and need not repeat a medical and laboratory examination if the patient received a medical and laboratory exam within the previous year, provided:

(1) The patient's prior medical records must be combined with the new medical records within thirty days of the patient's readmission;

(2) each program must immediately readmit patients who were previously discharged from that program:

(i) after a stay of 30 days or more in a hospital, nursing home, or other health care facility, if such patient is still being maintained on an approved medication, and/or meets the eligibility requirements when released; or

(ii) after an extended incarceration (including KEEP), if clinically appropriate when such patient is released.

(g) Transfers between OTPs.

(1) Each program must develop procedures regarding the transfer of patients which must ensure that the program shall:

(i) not deny a reasonable request for a temporary or permanent transfer;

(ii) not include "temporary-to-permanent" conditions, whereby a patient is temporarily provided guest medication and then evaluated as to whether or not the OTP will permanently admit, unless otherwise authorized by the Office;

(iii) regard transferred patients as continuing in treatment by incorporating their length of treatment and treatment/recovery plans from the referring program;

(iv) send or receive the reason for the transfer and provide the most current medical, counseling, and laboratory information within fourteen (14) days of the request. Receipt of this information is not required prior to acceptance and the failure to receive this information will not preclude acceptance; and

(v) continue the patient's approved medication dosage and take-home schedule unless new medical or clinical information requires medical staff to review and subsequently order a change.

(2) Each program must develop procedures for the temporary transfer of patients which must ensure that the:

(i) transferring programs forward information on fees, contact person, time and dose of medication to the receiving program;

(ii) Program sends or receives prior to the patient's arrival the reason for the temporary transfer including temporary dates and approved medication dose;

(iii) Program shall not deny a reasonable request for a temporary transfer;

(iv) transferring program remains responsible for the patient's overall treatment. The receiving program may deliver any necessary service after consultation with the transferring program; and

(v) receiving program prescribing professional must write an order to continue the patient's medication dose and take-home schedule.

(h) Treatment/recovery plan.

(1) Each patient must have a written person-centered treatment/recovery plan developed by the clinical staff person with primary responsibility for the patient, in collaboration with the patient and anyone identified by the patient as supportive to recovery goals. The treatment/recovery plan begins with the assessment incorporated into the patient record and is regularly updated with progress notes.

(i) Minor patients: If the patient is a minor, the treatment/recovery plan must also be developed in consultation with the patient's parent or guardian unless the minor is being treated without parental consent as authorized by Mental Hygiene Law section 22.11.

(ii) Immediate transfer: For patients moving directly from one program 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 patient goals as appropriate.

(2) The treatment/recovery plan must:

(i) include the assessment, which identifies each diagnosis for which the patient is being treated;

(ii) be incorporated into the patient record through regular progress notes, including initial services to be offered prior to completion of the initial assessment;

(iii) address patient goals as identified through the assessment process and regularly updated as needed through progress notes;

(iv) identify a single member of the clinical staff responsible for coordinating and managing the patient's treatment who shall approve and sign (physical or electronic signature) such plan;

(v) reference to any significant medical and psychiatric issues, including all medications, by acknowledging review of medical/psychiatric assessment and progress notes, as well as coordination with mental and psychiatric providers; and

(vi) be reviewed and approved by the clinical staff person responsible for developing the plan, the patient and the clinical supervisor.

(i) Continuing review of treatment/recovery plans. The treatment/recovery plan must be reviewed through the ongoing assessment process and regular progress notes.

(j) Progress Notes. Progress notes are intended to document the patient's clinical status. Service delivery should be documented in the patient record through regular progress notes that include, unless otherwise indicated, the type, content, duration and outcome of each service delivered to or on behalf of a patient, described and verified as follows:

(1) be written and signed (physical or electronic signature) by the staff member providing the service;

(2) indicate the date the service was delivered;

(3) record the relationship to the patient's developing treatment goals described in the treatment/recovery plan; and

(4) include, as appropriate and relevant, any recommendations, communications, or determinations for initial, continued or revised patient goals and/or treatment.

(k) The program's multidisciplinary team, as defined in Part 800 of this Title, shall meet on a regularly scheduled basis for the purpose of reviewing a sample of cases for the purpose of clinical monitoring of practice. This meeting shall be documented as to date, attendance, cases reviewed and recommendations.

(l) Pregnancies. Treatment/recovery plans must include provisions for pre-natal care for all patients who are pregnant or become pregnant. If a pregnant patient refuses or fails to obtain such care, the provider must have the patient acknowledge in writing that pre-natal care was offered, recommended, and refused. The program should also offer to develop a plan of safe care with the patient and anyone identified by the patient, such offer should be noted in the patient record.

(m) Communicable disease. 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 patient refuses to obtain such care, the provider must have the patient acknowledge in writing that such care was offered, recommended, and refused.

(n) Transfers. If patients are transferred between a SUD outpatient program and outpatient rehabilitation services within the same provider, a single patient record may be maintained provided that it includes clinical justification for the transfer, the effective date of the transfer and a revised treatment/recovery plan, if necessary, signed (physical or electronic signature) by a clinical staff member and their supervisor.

(o) Confidentiality. Patient records maintained by the program are confidential and may only be disclosed consistent with the Health Insurance Portability and Accountability Act (HIPAA) and the federal regulations governing the confidentiality of patients' records as set forth in 42 CFR Part 2 and other applicable law.

(p) Records retention. Patient records must be retained for ten (10) years after the date of discharge or last contact, or three (3) years after the patient reaches the age of eighteen, whichever time period is longer.

(q) Patient deaths. If a patient dies while in active treatment any known details must be documented in the patient record.

(r) Transition or discharge criteria.

(1) Patients having no contact or intent to continue accessing services from a program should be discharged after a period not exceeding sixty (60) days unless reason for continuing treatment past that period is identified and documented in the patient record.

(2) Individuals entering treatment should progress by meeting treatment milestones including: stabilization; engagement; goal setting; and attainment of patient-centered goals. Individuals should be considered for transitions to the community or another level of care once they have stabilized and attained the support necessary to support their goals. If an individual leaving treatment expresses a preference for a level of care or services that preference should be included in the patient record.

(3) Individuals who are discharged involuntarily must be discharged consistent with Part 815 of this Title.

(4) Transition plan.

(i) A transition plan must be developed in collaboration with the patient and any collateral person(s) the patient chooses to involve. Such plan shall specify needed referrals with appointment dates and times, all known medications (including frequency and dosage) and recommendations for continued care.

(ii) The transition plan shall include an appointment with an appropriate provider to continue access to approved medications to treat the patient's substance use disorder.

(iii) If the patient is a minor, the plan must also be developed in consultation with their parent or guardian, unless the minor is being treated without parental consent as authorized by Mental Hygiene Law section 22.11; information pertaining to the testing and treatment of sexually transmitted infections cannot be shared with the minor patient's parent or guardian without the patient's consent, in accordance with applicable laws and regulations.

(5) No patient may be discharged without a plan which has been previously reviewed and approved by a clinical staff member and the clinical supervisor. This requirement does not apply to patients who stop attending, or otherwise fail to cooperate, or refuse continuing care or OBOT planning. That portion of the transition plan which includes referrals for continuing care must be given to the patient prior to leaving the program. The patient, and their family/significant other(s), shall be offered overdose prevention education and training, and a naloxone kit or prescription.

(s) Continuing Care. Individuals may be admitted to continuing care when they require a less intensive amount of support and services and there is a documented clinical need for ongoing clinical support to maintain gains made in treatment.

(1) The purpose of continuing care is to provide ongoing disease management services including management of life stressors, urges and cravings, mood and interpersonal relationships and to maintain gains made in treatment.

(2) Individuals in continuing care may receive counseling or peer services, rehabilitative support services including case management and medication management services as needed.

(3) Patients receiving OTP services are not appropriate for continuing care as defined herein.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 822.8

Adopted New York State Register December 9, 2015/Volume XXXVII, Issue 49, eff. 11/20/2015

Amended New York State Register December 6, 2017/Volume XXXIX, Issue 49, eff. 12/6/2017

Adopted New York State Register March 27, 2019/Volume XLI, Issue 13, eff. 3/27/2019

Amended New York State Register January 27, 2021/Volume XLIII, Issue 04, eff. 1/27/2021

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