Current through Register Vol. XLI, No. 50, December 13, 2024
Section 69-8-10 - Provision and Coordination of Patient Care10.1. Each pain management clinic shall develop and maintain current policies and procedures, patient protocols, treatment plans, and profiles for the treatment of patients seeking treatment for chronic pain.10.2. Assessments. 10.2.1. All patients shall undergo an initial assessment in order to determine the patient's condition, diagnosis, and treatment. The assessment shall be conducted by one or more physicians who specialize in the treatment of the area, system, or organ of the body perceived as the source of the pain.10.2.2. The initial assessment shall include documentation of: 10.2.2.a. A physical examination, by a qualified medical professional working within their scope of practice;10.2.2.b. The patient's health history;10.2.2.c. All current medications, prescription or otherwise;10.2.2.d. The patient's use of alcohol, tobacco, or other substances;10.2.2.e. Determination of current dependence on controlled substances;10.2.2.f. An inquiry to and report from the Controlled Substances Monitoring Program;10.2.2.g. Laboratory tests;10.2.2.h. A full toxicology screen;10.2.2.i. An inquiry whether the patient is being treated at any other pain management clinic;10.2.2.j. The diagnosis of all conditions, including a diagnosis of chronic pain, if applicable, including signs, symptoms, and causes;10.2.2.k. A copy of the report by the referring physician and any medical records from other providers; and10.2.2.l. The dates, amounts, and dosage forms of any drugs prescribed, dispensed, and administered.10.2.3. Subsequent patient assessments shall include documentation of: 10.2.3.a. Follow-up physical examinations, by a qualified medical professional working within their scope of practice;10.2.3.b. The patient's response to treatment;10.2.3.c. Any modification to the plan of treatment;10.2.3.d. The dates on which any medications were prescribed, dispensed, or administered;10.2.3.e. The amounts and dosage forms for any drugs prescribed, dispensed, or administered;10.2.3.f. Laboratory tests, according to the pain management clinic's policy, but at least every 60 days; and10.2.3.g. Full toxicology screen, according to the pain management clinic's policy, but at least every 90 days.10.2.4. A physician, physician assistant, certified registered nurse anesthetist, or advance practice registered nurse shall perform a physical examination of a patient on the same day that the physician initially prescribes, dispenses, or administers a controlled substance to a patient. If the patient continues to be treated for chronic pain at the clinic, a physical examination shall be performed at least four times, or every 90 days, per year thereafter. All examinations shall be performed according to accepted and prevailing standards for medical care.10.3. Plan of care.10.3.1. The treating physician and other health care professionals, working within their scope of practice, directly involved in the care of the patient shall develop a written individualized plan of care for every patient.10.3.2. The plan of care shall include, at a minimum: 10.3.2.a. Information required for the initial assessment;10.3.2.b. Documentation of the patient's diagnoses, the proposed medical treatment, medication dosages, and administration;10.3.2.c. Documentation of the patient's current physical condition and whether the patient requires other health care;10.3.2.d. Laboratory test results;10.3.2.e. Follow-up on any identified medical, physical, or behavioral health issues;10.3.2.f. Documentation of any education regarding the management of chronic pain, suggested pain management programs or counseling sessions and resolution of other issues unique to the needs of the patient;10.3.2.g. Such other information as recommended by the guidelines and treatment model utilized for the patient;10.3.2.h. Specific goals and outcomes to improve or maintain the optimal health of the patient which are based on the assessment of the patient; and10.3.2.i. A description of services and their frequency to be provided for the patient and primarily directed to achieve the expected goals and outcomes.10.3.3. Delivery of patient care and treatment interventions shall be based on the needs identified in the plan of care.10.3.4. The plan of care shall be reviewed by the patient and health care professionals directly involved in the care of the patient at least every 90 days and documented in the patient record. Reviews shall address each of the objectives identified on the initial plan of care; document all treatment, medications, and other services rendered to the patient; and document the patient's progress. A revised plan of care may be implemented with each review. Paper and electronic plans of care, including all reviews and updates, must be acknowledged by the patient.10.3.5. When a physician diagnoses an individual with chronic pain, the physician may treat the pain by managing it with medications in amounts or combinations that may not be appropriate when treating other medical conditions.10.4. Medication Security and Administration. 10.4.1. A person may not dispense any medication, including a controlled substance, on the premises of a licensed pain management clinic unless he or she is a physician or pharmacist licensed in this state. A pain management clinic physician or pharmacist shall not dispense to any patient more than a 72-hour supply of any controlled substance.10.4.2. The pain management clinic shall comply with policies and procedures developed by the West Virginia Board of Pharmacy that permit physicians access to the Controlled Substances Monitoring Program database maintained by the West Virginia Board of Pharmacy. The treating physician shall access the Controlled Substances Monitoring Program database in order to ensure that the patient is not seeking prescription medication from multiple sources. The results obtained from the database shall be maintained with the patient records. Treating physicians shall access the database:10.4.2.a. At the patient's intake;10.4.2.b. Before administering, dispensing, or prescribing any controlled substance;10.4.2.c. At each 90-day examination;10.4.2.d. After any positive drug test; and10.4.2.e. Whenever the treating physician, in his or her discretion, believes a review of the database is warranted.10.4.3. The pain management clinic shall have policies and procedures that comply with all relevant federal and state laws, rules, and regulations regarding the storage, management, administration, and dispensing of medications kept at the facility. In addition, the policies and procedures shall include measures that: 10.4.3.a. Ensure responsible handling and appropriately locked storage of all medications kept, received, stored, administered, or dispensed at the facility;10.4.3.b. Ensure accurate documentation of all medications kept, received, stored, administered, and dispensed at the facility;10.4.3.c. Ensure that only authorized personnel may access the storage areas where any medications are kept; and10.4.3.d. Ensure any outdated drugs and drug containers with worn, illegible, or missing labels are removed from the pain management clinic in accordance with the requirements for safe medication disposal from the Board of Pharmacy, as well as the pain management clinic policy.10.4.4. The pain management clinic shall maintain current policies and procedures which ensure that all medications are administered or dispensed in accordance with approved product labeling. The procedures must ensure that any significant deviations from the approved labeling, including deviations with regard to dose frequency, or the conditions of use described in the approved labeling, are specifically documented in the patient's record.10.4.5. Each pain management clinic shall calibrate medication dispensing instruments consistent with the manufacturer's recommendations to ensure accurate patient dosing and substance tracking.10.4.6. Each pain management clinic is responsible for proper documentation of medications kept, received, stored, administered, or dispensed. Documentation of medication administered or dispensed requires, at a minimum, the following: 10.4.6.a. The signature or initials of the qualified person administering or dispensing medication;10.4.6.b. The date and time of dispensing;10.4.6.c. The exact number of milligrams of the substance administered or dispensed;10.4.6.d. The daily totals of the substance administered or dispensed;10.4.6.e. Each dosage administered, dispensed, prepared, or received shall be recorded and accounted for by written, signed notation in a manner that creates a perpetual and accurate inventory of all medications in stock at all times;10.4.6.f. Each medication order and dosage change shall be written on an acceptable order sheet and signed and dated by only the treating physician. If the initials are used, the full signature of the qualified person administering or dispensing shall appear at the end of each page of the medication sheet; and10.4.6.g. At the time any medication is administered or dispensed, each dose shall be recorded on an administration sheet; in the medication dose history included in the patient's plan of care and patient chart; and in the inventory control program used by the facility to monitor and ensure an accurate inventory of all medication on the premises.10.4.7. The pain management clinic shall establish policies and procedures for monitoring medications to prevent diversion. The policies and procedures may include random call backs of individuals who are prescribed controlled substances on an ongoing basis, required clinic appointments, random toxicology screens, and random medication counts.10.4.8. Every pain management clinic physician authorized to prescribe controlled substances is responsible for maintaining the control and security of his or her prescription blanks and any other method used for prescribing controlled substance pain medication. 10.4.8.a. Each physician shall comply with all state and federal requirements for tamper-resistant prescription paper.10.4.8.b. In addition to any other requirements imposed by statute or rule, each physician shall notify the secretary in writing within 24 hours following any theft or loss of a prescription blank or a breach of any other method for prescribing pain medication.10.4.9. The pain management clinic shall establish policies and procedures regarding safe keeping, monitoring, destruction, and accounting for any medications the patient brings into the clinic.10.4.10. Every pain management clinic must develop procedures for the destruction of medications in accordance with the Board of Pharmacy requirements and to include at least two employees, one of which must be a licensed medical professional.