W. Va. Code R. § 69-11-27

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

Section 69-11-27 - Provision of Coordination of Patient Care; Post-Admission Assessment and Initial Plan of Care

27.1. Each MAT program shall develop, implement and maintain current policies and procedures, patient protocols, treatment plans and profiles for the treatment of patients seeking treatment for medication-assisted treatment.

27.2. Initial Post-Admission Assessments.

27.2.a. All patients undergo an initial post-admission assessment in order to determine the patient's condition, diagnosis and treatment. The assessment shall be conducted by one or more program physicians.

27.2.b. Upon admission to a MAT program, each patient shall undergo an initial post-admission assessment and the MAT program shall develop an initial plan of care. The initial assessment and plan of care shall be completed within seven days of the patient's admission.

27.2.c. The initial post-admission assessment shall consist of a medical assessment and include documentation of:

27.2.c.1. A physical assessment by a qualified medical professional within their scope of practice;

27.2.c.2. A psychiatric assessment, including mental status examination and psychiatric history;

27.2.c.3. A personal and family medical and health history;

27.2.c.4. All current medications, prescription or otherwise;

27.2.c.5. A comprehensive history of substance abuse, both personal and family;

27.2.c.6. Determination of current dependence on controlled substances;

27.2.c.7. A tuberculosis screening;

27.2.c.8. A screening test for syphilis;

27.2.c.9. A hepatitis C test;

27.2.c.10. An HIV test to the extent voluntarily elected by the patient;

27.2.c.11. An inquiry to and report from the Controlled Substances Monitoring Program database;

27.2.c.12. Laboratory tests;

27.2.c.13. A full drug screen;

27.2.c.14. An inquiry whether the patient is being treated at any other MAT program;

27.2.c.15. The diagnosis of all conditions, including a diagnosis of substance use disorder, including signs and symptoms;

27.2.c.16. A copy of the report by the referring physician and any medical records from other providers, if applicable;

27.2.c.17. The dates, amounts and dosage forms for any drugs prescribed, dispensed and administered; and

27.2.c.18. Other tests as necessary or appropriate, including, but not limited to, CBC, EKG, X-ray, pap smear, hepatitis B surface antigen and hepatitis B antibody testing.

27.2.d. A program physician or supervised physician extender shall perform a physical assessment of a patient on the same day that the program physician initially prescribes, dispenses or administers a medication-assisted treatment medication to a patient. If the patient continues to be treated for substance use disorder at the program, an assessment shall be performed at least every 90 days thereafter. All assessments shall be performed according to accepted and prevailing standards for medical care.

27.2.e. A repeat, full drug screen may be completed at 14 days after admission to identify whether the patient is using other drugs or substances, including, but not limited to, opiates, methadone, buprenorphine, amphetamines, cocaine, barbiturates, benzodiazepines and marijuana.

27.2.f. The initial post-admission assessment may include laboratory tests conducted by the MAT program or by other reliable sources.

27.2.f.1. Laboratory tests that are not directly conducted by the MAT program may be provided by the patient's primary care physician, other health care providers or by a medical clinic.

27.2.f.2. The MAT program is responsible for obtaining and maintaining documentation of required laboratory tests performed by an alternative provider. Alternative providers may not supply drug screens unless they meet the required quality guidelines, content and timelines according to section 34 of this rule.

27.2.f.3. Tests not directly conducted by the MAT program at admission shall have been conducted within the 30 days prior to the admission in order to be considered a valid assessment of the patient.

27.3. Continued Post-Admission Assessments. Subsequent patient assessments shall include documentation of:

27.3.a. Follow-up physical assessments, by a program physician or a supervised physician extender;

27.3.b. The patient's response to treatment;

27.3.c. Any modification to the plan of treatment;

27.3.d. The dates on which any medications were prescribed, dispensed or administered;

27.3.e. The amounts and dosage forms for any drugs prescribed, dispensed or administered;

27.3.f. Laboratory tests; and

27.3.g. Full drug screens.

27.4. Initial Plan of Care.

27.4.a. The treating program physician and other health care professionals, working within their scope of practice, directly involved in the care of the patient shall develop a written initial plan of care for every patient.

27.4.b. The initial plan of care shall include, at a minimum:

27.4.b.1. Information required for the initial assessment;

27.4.b.2. Documentation of the patient's diagnoses, the proposed medical and medication-assisted treatment, medication dosages and administration;

27.4.b.3. Documentation of the patient's current physical condition and whether the patient requires other health care services;

27.4.b.4. Laboratory test results;

27.4.b.5. Follow-up on any identified medical, physical or behavioral health issues;

27.4.b.6. Documentation of any education regarding the MAT program's policies and procedures, substance use disorder or counseling sessions and resolution of other issues unique to the needs of the individual patient;

27.4.b.7. Such other information as recommended by the guidelines and treatment model utilized for the patient;

27.4.b.8. Specific goals and outcomes to improve or maintain the optimal health of the patient which are based on the assessment of the patient; and

27.4.b.9. A description of services and their frequency to be provided for the patient and primarily directed to achieve the expected goals and outcomes.

W. Va. Code R. § 69-11-27