Current through Register Vol. XLI, No. 50, December 13, 2024
Section 69-7-34 - Individualized Treatment Plan of Care34.1. Within thirty days after admission of a patient, the opioid treatment program shall develop a more comprehensive individualized treatment plan of care and attach it to the patient's chart no later than five days after the plan is developed. The individualized treatment plan of care shall be developed pursuant to the guidelines and protocols established by American Society of Addiction Medicine (ASAM), the Center for Substance Abuse Treatment (CSAT) and the National Institute on Drug Abuse (NIDA), the American Association for the Treatment of Opioid Dependence (AATOD), or such other nationally recognized authority approved by the secretary. The individualized treatment plan of care shall include a recovery model based upon the approved guidelines and protocols.34.2. The individualized treatment plan of care of care shall be reviewed by the patient and staff at least each ninety days. Reviews shall be written and detailed. The quarterly review shall address each of the objectives identified on the initial individualized treatment plan of care; document all treatment, counseling, medications and other services rendered to the patient; and document the patient's progress towards recovery.34.3. The initial and quarterly individualized treatment plans of care shall be developed by the patient and the patient's counselor, with input as appropriate from medical staff. The individualized treatment plan of care shall be drafted to meet the specific needs of the patient. After the individualized treatment plan of care of care is developed and approved by the patient, the plan of care shall be placed in the patient's chart within five days of development. The patient shall receive a copy of all of his or her individualized treatment plans of care.34.4. All individualized treatment plans of care shall include, at a minimum: 34.4.a. Documentation of the patient's diagnoses; the proposed medical treatment and counseling; medication dosages and administration;34.4.b. A requirement that the patient regularly attend and participate in the opioid treatment program, both medical and counseling aspects, as determined necessary by the staff and patient;34.4.c. The identification of "triggers" for misuse of substances;34.4.d. The development and use of coping strategies for each "trigger";34.4.e. The development of a detailed relapse prevention plan;34.4.f. Meaningful follow-up on any identified behavioral health issues;34.4.g. Follow-up on medical or physical issues as necessary;34.4.h. A vocational evaluation, formal or informal;34.4.i. A plan to achieve financial stability and independence;34.4.j. A requirement that the patient abstain from use of illicit substances or abuse of prescription substances;34.4.k. Documentation of other individual or familial issues as relevant and appropriate and the proposed means of addressing such issues;34.4.l. The success of the patient's treatment, initiatives and goals;34.4.m. The results from initial, monthly and random drug tests;34.4.n. Such other information as recommended by the guidelines and recovery model utilized for the patient.34.5. The individualized treatment plan of care shall reflect the patient's current physical health condition and whether the patient requires other health care. Opioid treatment programs without primary care services onsite shall refer patients for appropriate laboratory tests and additional medical treatment and follow up on the results.34.6. Each opioid treatment program shall provide opportunities for family involvement in the therapy provided to each patient and document such involvement in the individualized treatment plans of care.34.7. The medical staff shall conduct careful discussions with the patient regarding the patient's continued desire to remain in the opioid treatment program on a maintenance schedule of medication and document such discussions in the patient's chart and individualized plans of care. 34.7.a. Opioid treatment programs shall make every effort to retain patients in treatment as long as clinically appropriate and medically necessary in accordance with approved national guidelines and acceptable to the patient.34.7.b. At the time of the quarterly review, the patient shall again be presented with the option of participating in alternative treatment, such as medically-supervised withdrawal. The patient shall sign and date a statement indicating whether he or she wishes to participate in an alternative form of treatment or remain within the program in an ongoing recovery-oriented maintenance format. The statement shall be included with the patient's individualized treatment plan of care.34.7.c. If the patient chooses the option of participating in alternative treatment, the individualized treatment plan of care shall include a consent form signed by the patient acknowledging that under the detoxification protocol the strength of maintenance doses of methadone should decrease over time; the treatment will be limited to a defined period of time, and that the participant is required to work toward a drug-free lifestyle.34.7.d. A patient in good standing with the facility, as defined by policy, has the right to continued stay in the program. At no time should such a patient feel pressured to enter a program of withdrawal over his or her objections.34.7.e. If a patient wishes to enter medically-supervised withdrawal, the individualized treatment plan of care shall reflect that choice.34.7.f. If at any time a patient in good standing wishes to re-enter a maintenance program, the patient may do so in consultation with the primary counselor and medical staff.34.8. With the patient's permission, the opioid treatment program shall obtain complete medical records from other providers and maintain the records in the patient chart and the individualized treatment plan of care.