DEPARTMENT OF COMMUNITY HEALTH

                 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

                        PART 7. OUTPATIENT PROGRAMS


R  325.14701   Program staffing; admissions; criteria; forms; policies and
procedures; information; eligibility.
  Rule 701. (1) The equivalent of 1 or more full-time counselors shall  be
available for approximately 40 clients.
  (2) Clearly stated written criteria for determining the  eligibility  of
individuals for admission shall be developed.
  (3) Information gathered in the course  of  the  intake  and  assessment
process shall be recorded on internally standardized forms. The  completed
forms shall become part of the applicant's case record.
  (4) A program shall develop written policies and  procedures  to  govern
the intake process which shall set forth both of the following:
  (a) The procedures to be followed when accepting referrals from  outside
agencies or organizations.
  (b) The procedures to be followed, including those for  referrals,  when
an applicant is found ineligible for admission.
  (5) All of the following information shall be collected and recorded for
all applicants before, or at the time of, admission:
  (a) Name, address, and telephone number, when applicable.
  (b) Date of birth and sex.
  (c) Family and social history.
  (d) Educational history.
  (e) Occupation.
  (f) Legal and court-related history.
  (g) Present substance abuse problem.
  (h) Date the information was gathered.
  (i) Signature of the staff member gathering the information.
  (j) Name of referring agency, when appropriate.
  (k) Address, telephone number, and name of nearest relative  to  contact
in case of emergency.
  (l) History of current and past  substance  abuse  or  other  counseling
services received. The agency, type of service, and the date  the  service
was received shall be indicated.
  (m) Name, address, and telephone number of the  most  recent  family  or
private physician.
  (n) A substance abuse history, including  information  about  prescribed
drugs and alcohol which indicates, at a  minimum,  all  of  the  following
information:
  (i) Substances used in the past, including prescribed drugs.
  (ii) Substances used recently, especially those used within the last  48
hours.
  (iii) Substances of preference.
  (iv) Frequency with which each substance is used.
  (v) Previous occurrences of overdose, withdrawal,  or  adverse  drug  or
alcohol reactions.
  (vi) History of previous substance abuse treatment received.
  (vii) Year of first use of each substance.
  (6) During the admission process, every effort shall be made  to  assure
that an applicant understands all of the following:
  (a) General nature and objectives of the program.
  (b) Rules that govern client conduct and infractions that  can  lead  to
disciplinary action or discharge from the program.
  (c) Hours during which services are available.
  (d) Costs to be borne by the client, if any.

  History:  1981 AACS.


R  325.14702   Withholding information.
  Rule 702. (1) An applicant  shall  retain  the  right  to  withhold  any
information that is not demonstrably necessary to the treatment process or
to essential program operations.
  (2) If a program finds it necessary to require  certain  information  in
addition to that described in R 325.14701(5) and (6)  as  a  condition  of
admission, there shall be a written policy delineating  such  information.
  (3) If an applicant refuses to divulge  such  additional  and  necessary
information, the refusal shall be noted in the client case record.

  History:  1981 AACS.


R  325.14703   Admission ineligibility.
  Rule 703. If an applicant is found to be ineligible for  admission,  the
reason shall be recorded in the client case record and, if appropriate,  a
referral to an appropriate agency or organization shall be attempted.

  History:  1981 AACS.


R  325.14704   Medical examination and information.
  Rule 704. (1) A program that does not require a medical examination  for
admission shall make a determination of the necessity or advisability of a
medical examination for each client.
  (2) At the time of admission, inquiry shall be made to  determine  if  a
client  has  any  physical   disabilities,   limitations,   or   ailments.
Disabilities, limitations, and ailments shall be recorded  in  the  client
file.
  (3) Based upon medical information provided  by  the  client,  referrals
shall be made to  a  licensed  physician  as  deemed  appropriate  by  the
counselor. Action taken shall be recorded in the client file.

  History:  1981 AACS.


R  325.14705   Treatment plans.
  Rule 705. (1) There shall be an assessment of each client's  social  and
psychological needs. The areas of concern shall include a determination of
the following:
  (a) Current emotional state.
  (b) Cultural background.
  (c) Vocational history.
  (d) Family relationships.
  (e) Educational background.
  (f) Socioeconomic status.
  (g) Any legal problems that may affect the treatment plan.
  (2) Based upon the assessments made  of  a  client's  needs,  a  written
treatment plan shall be  developed  and  recorded  in  the  client's  case
record. A treatment plan shall be developed as  soon  after  the  client's
admission as feasible, but before  the  client  is  engaged  in  extensive
therapeutic activities. The treatment plan shall conform  to  all  of  the
following:
  (a) Be individualized based upon the assessment of  the  client's  needs
and, if applicable, the medical evaluation.
  (b) Specify those services planned for meeting the client's needs.
  (c) Include referrals  for  services  which  are  not  provided  by  the
outpatient care component.
  (d) Contain clear and concise statements of the  objectives  the  client
will be attempting to achieve, together with a realistic time schedule for
their achievement.
  (e) Define the services to be provided to the  client,  the  therapeutic
activities in which  the  client  is  expected  to  participate,  and  the
sequence in which services will be provided.
  (3) Review of, and changes in, the treatment plan shall be  recorded  in
the client's case record. The date of the review of change, together  with
the names of the  individuals  involved  in  the  review,  shall  also  be
recorded. A treatment plan shall be reviewed at least once every  90  days
by the program director or his or her designee.

  History:  1981 AACS.


R  325.14706   Client counseling.
  Rule 706. Two or more hours of formalized individual, group,  or  family
counseling shall be available to each  client  each  week.  The  hours  of
counseling actually provided should vary according to  the  needs  of  the
client.

  History:  1981 AACS.


R  325.14707   Progress notes.
  Rule 707. (1) A client's progress and  current  status  in  meeting  the
objectives established in the treatment plan, together with a statement of
the efforts by staff members to  help  the  client  achieve  these  stated
objectives, shall be recorded in the client's case record for every formal
client counseling session. A progress note shall be dated  and  signed  by
the individual who makes the entry.
  (2) If a client is  receiving  services  at  an  outside  resource,  the
program shall attempt to secure a written case summary,  case  evaluation,
and other client records from that resource. These records shall be  added
to the client's case record.
  (3) The ongoing assessment  of  the  client's  progress  in  respect  to
achieving treatment plan objectives shall be used to update the  treatment
plan.

  History:  1981 AACS.


R  325.14708   Client discharges.
  Rule 708. (1) Within 2 weeks after discharge, the counselor shall  enter
in the client's case record a discharge summary describing  the  rationale
for  discharge,  the  client's  treatment  and  rehabilitation  status  or
condition at discharge, and the instructions given  to  the  client  about
aftercare and follow-up.
  (2) Unless a client leaves voluntarily  before  his  or  her  course  of
treatment is completed, a client shall not be discharged  from  a  program
while physically dependent upon a drug prescribed for him or  her  by  the
program physician, unless the client is given an opportunity  to  withdraw
from the drug under medical supervision and at a rate  determined  by  the
program physician or the client is referred to an outside  resource  which
is willing to continue administering the drug.
  (3) The offer to provide withdrawal  or  referral  to  another  resource
shall be made both orally and in writing. If the client  refuses  such  an
offer, the program shall attempt to secure a  signed  statement  from  the
client which verifies that the offer was made to, and was rejected by, the
client. Failing that, a progress note shall be  recorded  documenting  the
attempt.

  History:  1981 AACS.


R  325.14709   Aftercare plan.
  Rule 709. (1) If  a  program  provides  aftercare  services,  a  written
aftercare plan shall be developed in partnership with  the  client  before
the completion of treatment. The aftercare plan shall state the objectives
for the client for a reasonable period following discharge. The plan shall
also contain the description of the  services  the  program  will  provide
during the aftercare period, the procedure the  client  is  to  follow  in
reestablishing contact with the program, especially in  times  of  crisis,
and the frequency with which the  program  will  attempt  to  contact  the
client for purposes of follow-up.
  (2) The date, method, and  results  of  attempts  at  contact  shall  be
entered in the client's case record and shall be signed by the  individual
who makes the entry. If follow-up  information  cannot  be  obtained,  the
reason for failing to obtain the  information  shall  be  entered  in  the
client's case record.
  (3) Regardless of the method of  contact  utilized,  the  program  shall
protect the confidentiality of the  client.  Mailing  envelopes  that  are
identifiable as originating from the program shall  not  be  mailed  to  a
client. A post office box number may be used  to  determine  if  mail  was
undeliverable and to facilitate follow-up.

  History:  1981 AACS.


R  325.14710   Confidentiality of follow-up.
  Rule 710. If the program attempts to determine the status of clients who
have been discharged, and if this attempt is made for purposes other  than
determining the disposition of a referral or for research  purposes,  such
follow-up  shall  be  limited  to  methods  which  either  assure   client
confidentiality or require formal written consent of the client.

  History:  1981 AACS.


R  325.14711   Maintenance of client records.
  Rule 711. (1) There shall be a case record for each client. All  of  the
following items shall be filed in the case record, if applicable:
  (a)  Results  of  all  examinations,   tests,   and   other   assessment
information.
  (b) Reports from referring sources.
  (c) Treatment plans.
  (d) Records of referrals to outside resources.
  (e) Reports from outside resources, which shall include the name of  the
resource and the date of the report. These reports shall be signed by  the
person who makes the report or by the program staff  member  who  receives
the report.
  (f) Case conference and consultation notes, including the  date  of  the
conference or consultation, recommendations made, and actions taken.
  (g) Correspondence related to the  client,  including  all  letters  and
dated notations  of  telephone  conversations  relevant  to  the  client's
treatment.
  (h) Treatment consent forms.
  (i) Information release forms.
  (j) Progress notes. Entries shall be filed in  chronological  order  and
shall include the date any relevant observations were made, the  date  the
entry was made, and the signature and staff title of the person who  makes
the entry.
  (k) Records of services provided. Summaries of services  provided  shall
be sufficiently detailed so that a person who is  not  familiar  with  the
program can identify the types of services the client has received.General
terms such as "counseling" or "activities" shall be avoided in  describing
services.
  (l) Aftercare plans.
  (m) Discharge summary.
  (n) Follow-up information.
  (2) A program shall  provide  sufficient  facilities  for  the  storage,
processing, and security of client case records.  These  facilities  shall
include suitably locked and secured rooms and files.
  (3) Appropriate records shall  be  readily  accessible  to  those  staff
members who provide services directly to the client.
  (4) A client case record shall be maintained for not less than  3  years
after services are discontinued.
  (5) If a program stores client data on magnetic tape, computer files, or
other types of automated information systems, security measures  shall  be
developed to prevent inadvertent or unauthorized access to data files.

  History:  1981 AACS.


R  325.14712   Support and rehabilitative services.
  Rule 712. (1) All of the following support and  rehabilitative  services
shall be available  to  all  clients  either  internally  or  through  the
referral process:
  (a) Education.
  (b) Vocational counseling and training.
  (c) Job development and placement.
  (d) Financial counseling.
  (e) Legal counseling.
  (f) Spiritual counseling.
  (g) Nutritional education and counseling.
  (2) A program shall maintain a current  listing  of  services  available
on-site and by referral. This listing shall be reviewed with  each  client
as part of the program's orientation procedure.

  History:  1981 AACS.