W. Va. Code R. § 69-11-18

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-11-18 - Continuous Quality Improvement Policies, Diversion Control Plan

18.1. Each MAT program shall develop, implement and maintain current quality assurance and quality control plans that include provisions for:

18.1.a. Regular and continuous staff education;

18.1.b. An annual review, in consultation with the advisory council and the peer review committee of program policies and procedures;

18.1.c. A service delivery assessment which, at a minimum, shall evaluate appropriateness of the individualized treatment plan and services delivered, completeness of documentation in patients; records and quality of and participation in staff training programs, linkage to a utilization of primary care and other out-of-program services, and availability of services and medications for other conditions;

18.1.d. Consideration of ongoing input into program policies and procedures by patients regarding community concerns;

18.1.e. Development and implementation of annual patient satisfaction surveys that include a review of patient satisfaction;

18.1.f. An ongoing assessment, measurement and monitoring of patient outcomes, treatment outcomes and the various processes including, but not limited to:

18.1.f.1. Reduction or elimination of the patient's use of illicit opioids, illicit drugs and the problematic use of licit drugs;

18.1.f.2. Reduction or elimination of associated criminal activities;

18.1.f.3. Reduction of the patient's behaviors contributing to the spread of infectious diseases;

18.1.f.4. Improvement of quality of life through the restoration of physical and behavioral health and functional status, including employment or volunteerism, as may be appropriate; and

18.1.f.5. Assessment of medication-related issues, including, but not limited to, take-home procedures, security, inventory and dosage issues.

18.2. The MAT program shall annually collect outcome measurements and results of patient satisfaction surveys. The governing body and the advisory council shall review the results and submit the reports to the state authority.

18.3. Each MAT program shall participate in additional quality improvement outcome studies as directed by the designated state oversight authority.

18.4. A MAT program shall maintain a current "Diversion Control Plan" (DCP) as part of its quality assurance programs that contains specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use. The DCP shall assign specific responsibility to the medical and administrative staff of the MAT program for carrying out of the diversion control measures and functions described in the DCP.

18.4.a. The DCP shall be reviewed and approved by the governing body, advisory council and peer review council and the state opioid treatment authority.

18.4.b. The DCP shall minimize the diversion of methadone, in all forms, or other medication-assisted treatment medications to illicit use. The plan shall include:

18.4.b.1. Continuous clinical and administrative monitoring of the potential for and actual diversion including an investigation, tracking and monitoring system of incidents of diversion; and

18.4.b.2. Proactive planning and procedures for problem identification, correction and prevention.

18.4.c. The DCP shall contain, at a minimum, a random call-back program with mandatory compliance, which shall be in addition to the regular schedule of program visits.

18.4.c.1. Each patient receiving three or more consecutive doses of unsupervised or take-home medications shall be called back randomly within the 90-day period immediately following the previous call-back.

18.4.c.2. Upon call-back, a patient shall report to the program within 24 hours of notification, or sooner if directed by the physician, with all take-home medications. The quantity and integrity of packaging shall be verified for all doses. If a take-home dose shows evidence of tampering, the program shall impose uniform sanctions for violating take-home policies, including sanctions for a patient's tampering with a take-home dose, if applicable.

18.4.c.3. Patients shall be informed of consequences for violating the take-home policy.

18.4.c.4. The program shall maintain individual call-back results in the patient record and individualized treatment plan.

W. Va. Code R. § 69-11-18