S.C. Code Regs. § ch. 61, 61-93, 61-93.1100

Current through Register Vol. 48, No. 10, October 25, 2024

Section 61-93.1100 - PATIENT PHYSICAL EXAMINATION

A. Residential Facilities. A Physical Examination shall be completed by a Physician or other Authorized Healthcare Provider for Patients within thirty (30) calendar days prior to admission or two (2) business days of admission for Patients . Physical Examinations conducted by Physicians or other Authorized Healthcare Providers licensed in other states are permitted for new admissions under the condition that the Patient undergoes a second Physical Examination by a South Carolina licensed Physician or other Authorized Healthcare Provider within thirty (30) calendar days of admission to the Facility. The Physical Examination shall address:

1. The appropriateness of level of services;

2. Identification of special conditions and/or care required;

3. A tuberculin skin test, as described in Section 1702, unless there is a previously documented positive reaction;

4. If a Patient or potential Patient has a communicable disease, the Facility shall follow the recommendations made by a Physician or other Authorized Healthcare Provider in order to:

a. Ensure that the Facility has the capability of providing adequate care and preventing the spread of that condition, and that Staff and Volunteers are adequately trained; or

b. Transfer the Patient to an appropriate Facility, if necessary; and

5. A substance use test. Following the test, the Physician or Authroized Healthcare Provider shall determine the frequency of subsequent testing based on the Patient's clinical presentation.

B. In Facilities providing services for parents with children, there shall be a report of an examination for each child by a Physician or other Authorized Healthcare Provider attesting to the health status and special care needs that may impact the child, his/ or her parent, and/or others within the Facility. The examination shall be conducted not earlier than thirty (30) calendar days prior to the parent's admission or no later than forty-eight (48) hours after admission.

C. Opioid Treatment Program.

1. Physical Examination. A Physical Examination conducted by the Opioid Treatment Program Physician or other Authorized Healthcare Provider shall be completed within seventy-two (72) hours prior to the first dose of Opioid Treatment Program Medication and shall address the following at a minimum: (I)

a. Evidence of communicable or Infectious disease;

b. Pulmonary, liver, renal, and cardiac abnormalities;

c. Neurological issues;

d. Vital signs;

e. Evidence of clinical signs of dependency; and

f. Examination of head, ears, eyes, nose, throat, thyroid, chest (including heart, lungs and breast), abdomen, extremities, and skin.

2. Medical Laboratory Analysis. A medical laboratory analysis shall be conducted within seven (7) calendar days of admission and shall include:

a. Serological test for Infectious disease;

b. Initial substance use testing for Controlled Substance profile;

c. Liver profile; and

d. If indicated, an electrocardiogram, chest x-ray, and/or a biological pregnancy test.

3. In the event the medical staff are unable to obtain an adequate blood draw for the medical laboratory analysis on the first attempt, the Facility shall reattempt within the seven (7) days of admission. After three (3) documented attempts within the seven (7) days of admission, the Opioid Treatment Program Physician or other Authorized Healthcare Provider may waive the blood testing requirements. The Physician's decision shall be documented in the Patient's medical record. The Facility shall follow its policies and procedures related to infection control if the Physician waives the blood testing requirement.

D. In the event that a Patient transfers from one Residential Facility to another , an additional admission Physical Examination and/or tuberculin skin test shall not be necessary, provided the Physical was conducted not earlier than twelve (12) months prior to the admission of the Patient, and the Physical meets all other requirements specified in Section 1100.A.1, unless the receiving Facility has an indication that the health status of the Patient has changed significantly. In such instances of transfer, issues of appropriateness of level of treatment placement shall be addressed in the Patient record.

S.C. Code Regs. ch. 61, 61-93, 61-93.1100

Added by State Register Volume 44, Issue No. 06, eff. 6/26/2020.