W. Va. Code R. § 69-11-29

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

Section 69-11-29 - Individualized Treatment Plan of Care

29.1. Delivery of patient care and treatment interventions shall be based on the needs identified in the individualized treatment plan of care.

29.2. Within 30 days after admission of a patient, the MAT 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 the 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.

29.3. The individualized treatment plan of care shall be reviewed by the program physician, primary counselor and 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, counseling, 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. If a new plan of care is not implemented, the reasons for such decision should documented in the patient's record. Paper and electronic plans of care, including all reviews and updates, must be acknowledged by the patient.

29.4. The initial and quarterly individualized treatment plans of care shall be developed by the patient, the program physician and primary counselor, with input as appropriate from other health care providers. The individualized treatment plan of care shall be drafted to meet the specific needs of the patient. After the individualized treatment plan 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.

29.5. All individualized treatment plans of care shall include, at a minimum:

29.5.a. Documentation of the patient's diagnoses; the proposed medical treatment and counseling; medication dosages and administration;

29.5.b. A requirement that the patient regularly attend and participate in the MAT program, both medical and counseling aspects, as determined necessary by the staff and patient;

29.5.c. The identification of triggers for misuse of substances;

29.5.d. The development and use of coping strategies for each trigger;

29.5.e. The development of a detailed relapse prevention plan;

29.5.f. Meaningful follow-up on any identified behavioral health issues;

29.5.g. Follow-up medical or physical issues as necessary;

29.5.h. A vocational evaluation, formal or informal;

29.5.i. A plan to achieve financial stability and independence;

29.5.j. A requirement that the patient abstain from use of illicit substances, abuse of prescription substances or other substances of abuse;

29.5.k. Documentation of other individual or familial issues as relevant and appropriate and the proposed means of addressing such issues;

29.5.l. The success of the patient's treatment, initiatives and goals;

29.5.m. A description of services and their frequency to be provided for the patient and primarily directed to achieve the expected goals and outcomes;

29.5.n. The results from initial, monthly and random drug tests; and

29.5.o. Such other information as recommended by the guidelines and recovery model utilized for the patient.

29.6. The individualized treatment plan of care shall reflect the patient's current physical health condition and whether the patient requires other health care services. MAT programs without primary care services onsite shall refer patients for appropriate laboratory tests and additional medical treatment and follow up on the results.

29.7. Each MAT 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.

29.8. The medical staff shall conduct careful discussions with the patient regarding the patient's continued desire to remain in the MAT program on a maintenance schedule of medication and document such discussions in the patient's chart and individualized plans of care.

29.8.a. MAT 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.

29.8.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.

29.8.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 medication-assisted treatment medication should decrease over time and that the participant is required to work toward a recovery-oriented lifestyle.

29.8.d. A patient in good standing with the program, as defined by policy, has the right to continue to stay in the program. At no time should such a patient feel pressured to enter a program of withdrawal over his or her objections.

29.8.e. If a patient wishes to enter medically-supervised withdrawal, the individualized treatment plan of care shall reflect that choice.

29.8.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.

29.9. With the patient's permission, the MAT program shall obtain complete medical records from other health care providers, including counselors, and maintain the records in the patient's chart and the individualized treatment plan of care.

29.10. Coordination of Care Agreement.

29.10.a. The coordination of care agreement shall be signed by the patient, program physician and primary counselor. If a change of program physician or primary counselor takes place, a new agreement must be signed.

29.10.b. The coordination of care agreement shall be reviewed and updated at least annually. If the coordination of care agreement is reviewed, but not updated, the review shall be documented in the patient's record.

29.10.c. The coordination of care agreement shall include the following:

29.10.c.1. An authorization allowing communication between the program physician and primary counselor so that the patient may receive comprehensive and quality medication-assisted treatment;

29.10.c.2. The name and contact information for the program physician and primary counselor;

29.10.c.3. The categories of records which may be shared;

29.10.c.4. A summary of treatment and goals, diagnoses and services to be received onsite or by referral;

29.10.c.5. Current medications being prescribed, including dosage, frequency and delivery;

29.10.c.6. Date and prescription history for medication-assisted treatment medications; and

29.10.c.7. Estimated length of treatment.

29.10.d. The coordination of care agreement will be provided in a form prescribed and made available by the Secretary.

W. Va. Code R. § 69-11-29