Section 164.133 - Provision of Services(A)Admission. (1) The Licensed or Approved Provider shall determine the appropriate type of 24-hour diversionary service based upon the following: (a) Intensive 24-hour Diversionary Withdrawal Management Services (ASAM Level 4): Intensive 24-hour diversionary withdrawal management services are provided to patients who require this service type because:1. current and potential withdrawal symptoms are severe, constitute a risk to the patient's health and well-being and require frequent medical attention; and2. the patient's incapacity results from a substance use disorder or a mental or behavioral disorder due to psychoactive substance use.(b) 24-hour Diversionary Withdrawal Management Services (ASAM Level 3.7): 24-hour diversionary withdrawal management services are provided to patients who require this service type because:1. the patient's current or potential withdrawal symptoms constitute a risk to the patient's health and well-being and require medical monitoring; and2. the patient's incapacity results from a substance use disorder or a mental or behavioral disorder due to psychoactive substance use.(2)Initial Physical Assessment. Immediately upon admission a brief physical assessment of the patient shall be made by a qualified health care professional.(B)Assessments. Pursuant to 105 CMR 164.072(B), the Licensed or Approved Provider may initiate patient treatment prior to completion of the assessment required by 105 CMR 164.072 upon obtaining sufficient information to initiate treatment for the acute problem at the time of presentation and that the assessment is subsequently completed in a reasonable timeframe, provided that a Qualified Healthcare Professional must see such a patient or resident prior to initiating an FDA-approved medication for treatment of addiction.(C) In addition to the assessment required by 105 CMR 164.572, the Licensed or Approved Provider shall ensure an initial medical examination, which conforms to principles established by the American Society of Addiction Medicine, is completed for all patients within 24 hours of admission. (1) The physical examination shall include: (a) tests for the presence of opioids, alcohol, benzodiazepines, cocaine, all FDA-approved medications for addiction treatment, and any other drugs the Licensed or Approved Provider determines are clinically indicated or as approved by the Commissioner and listed in Department guidance;(b) a brief mental status exam; and(c) an assessment of pulmonary, liver, and cardiac abnormalities; dermatological and neurological sequelae of addiction; possible infectious serologies if indicated; possible concurrent surgical problems; and any other relevant laboratory studies as clinically indicated. These laboratory tests are not required to be completed prior to the initiation of medication for addiction treatment. Any relevant laboratory findings shall be documented and reviewed with the Medical Director and findings reviewed with the patient. Evidence of direct referrals to address findings shall be properly documented. The Licensed or Approved Provider shall ensure laboratory tests are completed by licensed facilities that comply with all applicable federal and state licensure and certification requirements.
(2) The license Licensed or Approved Provider shall also ensure the patient's current prescription medications are assessed in relation to interactions with medication prescribed in the course of treatment including, but not limited to, a review of MassPAT. Prior to prescribing, dispensing or administering an approved opioid agonist medication, the Licensed or Approved Provider shall ensure the approved medication is not contraindicated by the patient's current prescribed medications or health status.(3) For women of child-bearing age, the Licensed or Approved Provider shall include a pregnancy test in the physical examination.(4) If the examination is conducted by a qualified health care professional who is not a physician, the results of the examination and any recommendations arising from the examination shall be reviewed by the Medical Director or their delegated qualified healthcare professional prior to implementation.(5) All medical orders shall be signed by the Medical Director or their delegated qualified healthcare professional.(6) When readmitting a patient who had been admitted within the previous three months, the timing, frequency and interval of a complete physical examination shall be subject to Practitioner discretion, providing that no more than three months elapse between physical examinations.(7) If, within 30 calendar days of admission to 24-hour diversionary withdrawal management treatment, a patient is transferred to a different level of withdrawal management care, the Licensed or Approved Provider to whom the patient is transferred shall, with the patient's consent, request: (a) results of the physical examination described in 105 CMR 164.133(C)(1); and(b) for women of child-bearing age, results of the pregnancy and related tests described in 105 CMR 164.133(C)(3).(D)Diversion Control. The Licensed or Approved Provider shall maintain a diversion control plan using measures to reduce the possibility of diversion of controlled substances that are FDA-approved for the treatment of opioid dependency.(E)Treatment Services. (1) The Licensed or Approved Provider shall provide managed withdrawal treatment services as determined by the physical examination.(2) Once the patient receives medical clearance to participate, the Licensed or Approved Provider shall provide the patient with at least four hours of service programming each day. The programming shall include services specified in 105 CMR 164.074, and may be provided directly or through QSOAs.(3) The Licensed or Approved Provider shall provide at least one multidisciplinary team review for each patient stay.(F)Termination and Discharge. In addition to the termination and discharge requirements delineated in 105 CMR 164.075, the Licensed or Approved Provider's written procedures shall include the following provisions and shall incorporate these provisions into the policies as described in 105 CMR 164.040 and 105 CMR 164.081: (1) Criteria for medical discharge; and(2) Procedures for emergency and involuntary terminations in accordance with the following: (a) In an emergency situation, where the patient's continuation in the program presents an immediate and substantial threat of physical harm to other patients, program personnel or property or where the continued treatment of a patient presents a serious medical risk to the patient as determined by the medical director or the nurse-in-charge, the Licensed or Approved Provider may suspend a patient immediately and without provision for further withdrawal management or Referral. The patient shall be afforded the right to an appeal as described in the program policies and as required by 105 CMR 164.080.(b) In a nonemergency situation, wherein the patient's continuation does not present the immediate and substantial threat or serious medical risk described in 105 CMR 164.133(F)(2)(a), the Licensed or Approved Provider may not terminate the patient without first affording the patient the procedural rights defined in 105 CMR 164.079 and 105 CMR 164.080.Amended by Mass Register Issue 1482, eff. 11/11/2022.