317:30-5-95.47. Residential substance use disorder (SUD) - Individualized service plan requirements
All SUD services provided in residential treatment facilities are rendered as a result of an individual assessment of the member's needs and documented in the service plan.
(1) Assessment. A biopsychosocial assessment shall be completed for members receiving ASAM Level 3.1, 3.3, or 3.5 services, including dependent children receiving services from the residential SUD provider, to gather sufficient information to assist the member in developing an individualized service plan. The assessment must also list the member's past and current psychiatric medications. The assessment must be completed by an LBHP or licensure candidate. Licensure candidate signatures must be co-signed by a fully-licensed LBHP in good standing. Assessments for ASAM Level 3.7 services shall be completed in accordance with (E) below.
(A) Assessments for adolescents. A biopsychosocial assessment using the Teen Addiction Severity Index (T-ASI) shall be completed. A physical examination shall be conducted by a licensed physician to include, at a minimum, a physical assessment, health history, immunization status, and evaluation of motor development and function, speech, hearing, visual, and language functioning.
(B) Assessments for adults. A biopsychosocial assessment using the Addiction Severity Index (ASI) shall be completed.
(C) Assessments for dependent children. In accordance with OAC 450:18-7-25, assessments of children (including infants) accompanying their parent into treatment and receiving services from the residential SUD provider shall include the following items:
(i) Parent-child relationship;
(ii) Physical and psychological development;
(iii) Educational needs;
(iv) Parent related issues; and
(v) Family issues related to the child.
(D) Assessments for parents/pregnant women. In accordance with OAC 450:18-7-25, assessments of the parent and/or pregnant women bringing their children into treatment shall include the following items:
(i) Parenting skills;
(ii) Knowledge of age appropriate behaviors;
(iii) Parental coping skills;
(iv) Personal issues related to parenting; and
(v) Family issues as related to the child.
(E) Assessments for medically supervised withdrawal management. In accordance with OAC 450:18-13-61, a medical assessment for the appropriateness of placement shall be completed and documented by a licensed physician during the admission process.
(F) Assessment timeframes. Biopsychosocial assessments shall be completed within two (2) days of admission or during the admission process for medically supervised withdrawal management.
(2) Service plan. Pursuant to OAC 450:18-7-81, a service plan shall be completed for each member receiving ASAM Level 3.1, 3.3, or 3.5 services, including dependent children receiving services from the residential SUD provider. The service plan is performed with the active participation of the member and a support person or advocate, if requested by the member. In the case of children under the age of sixteen (16), it is performed with the participation of the parent or guardian, if allowed by law, and the child as age and developmentally appropriate. Service plans for ASAM Level 3.7 services shall be developed in accordance with (D) below.
(A) Service plan development. The service plan shall:
(i) Be completed by an LBHP or licensure candidate. Licensure candidate signatures must be co-signed by a fully-licensed LBHP in good standing.
(ii) Provide the formation of measurable service objectives and reflect ongoing changes in goals and objectives based upon member's progress or preference or the identification of new needs, challenges, and problems.
(iii) Be developed after and based on information obtained in the assessment and includes the evaluation of the assessment information by the clinician and the member.
(iv) Have an overall general focus on recovery which, for adults, may include goals like employment, independent living, volunteer work, or training, and for children, may include areas like school and educational concerns and assisting the family in caring for the child in the least restrictive level of care.
(B) Service plan content. Service plans must include dated signatures for the member [if over fourteen (14)], the parent/guardian [if under sixteen (16) and allowed by law], and the primary service practitioner. Signatures must be obtained after the service plan is completed. The contents of a service plan shall address the following:
(i) Member strengths, needs, abilities, and preferences;
(ii) Identified presenting challenges, needs, and diagnosis;
(iii) Goals for treatment with specific, measurable, attainable, realistic, and time-limited objectives;
(iv) Type and frequency of services to be provided;
(v) Description of member's involvement in, and response to, the service plan;
(vi) The service provider who will be rendering the services identified in the service plan; and
(vii) Discharge criteria that are individualized for each member and beyond that which may be stated in the ASAM criteria.
(C) Service plan updates. Service plan updates shall occur a minimum of once every thirty (30) days while services are provided. Service plan updates must include dated signatures for the member [if over fourteen (14)], the parent/guardian [if under sixteen (16) and allowed by law], and the LBHP and licensure candidate. Licensure candidate signatures must be co-signed by a fully-licensed LBHP in good standing. Signatures must be obtained after the service plan is completed. Service plan updates shall address the following:
(i) Progress on previous service plan goals and/or objectives;
(ii) A statement documenting a review of the current service plan and an explanation if no changes are to be made to the service plan;
(iii) Change in goals and/or objectives based upon member's progress or identification of new needs and challenges;
(iv) Change in frequency and/or type of services provided;
(v) Change in staff who will be responsible for providing services on the plan; and
(vi) Change in discharge criteria.
(D) Service plans for medically supervised withdrawal management. Pursuant to OAC 450:18-7-84, a service plan shall be completed for each member receiving ASAM Level 3.7 services that addresses the medical stabilization treatment and services needs of the member. Service plans shall be completed by a licensed physician or licensed registered nursing staff.
(E) Service plan timeframes. Service plans shall be completed within four (4) days of admission, except for service plans for individuals receiving medically supervised withdrawal management services, which must be completed within three (3) hours of admission.
(3) Progress notes. Progress notes shall chronologically describe the services provided, the member's response to the services provided, and the member's progress in treatment.
(A) Content. Progress notes shall address the following:
(ii) Member's name;
(iii) Start and stop time for each timed treatment session or service;
(iv) Signature of the service provider;
(v) Credentials of the service provider;
(vi) Specific service plan needs, goals and/or objectives addressed;
(vii) Services provided to address needs, goals, and/or objectives;
(vii) Progress or barriers to progress made in treatment as it relates to the goals and/or objectives;
(ix) Member (and family, when applicable) response to the session or service provided; and
(x) Any new needs, goals and/or objectives identified during the session or service.
(B) Frequency. Progress notes shall be completed in accordance with the following timeframes:
(i) Progress notes for therapy, crisis intervention and care management must be documented in an individual note and reflect the content of each session provided.
(ii) Documentation for rehabilitation and community recovery support services must include daily member sign-in/sign-out record of member attendance (including date, time, type of service and service focus), and a daily progress note or a summary progress note weekly.
(4) Transition/discharge planning. All facilities shall assess each member for appropriateness of discharge from a treatment program. Each member shall be assessed using ASAM criteria to determine a clinically appropriate placement in the least restrictive level of care.
(A) Transition/discharge plans. Transition/discharge plans shall be developed with the knowledge and cooperation of the member. The transition/discharge plan shall be included in the discharge summary. The discharge plan is to include, at a minimum, recommendations for continued treatment services and other appropriate community resources. Appointments for outpatient therapy and other services, as applicable, should be scheduled prior to discharge from residential care. Development of the transition/discharge plan shall begin no later than two (2) weeks after admission.
(B) Discharge summary. The discharge summary shall document the member's progress made in treatment and response to services rendered. A completed discharge summary shall be entered in each member's record within fifteen (15) days of the member completing, transferring, or discontinuing services. The summary must be signed and dated by the staff member completing the summary.