Appendix A T1464 Substance Abuse~1.docx

APPENDIX A

CORE PROGRAM STANDARDS

A. Levels of Care

1. Vendor[footnoteRef:1] shall offer the following levels of care: [1: Vendor refers to the provider agency/entity that is awarded the contract by DOC to provide SUD Program treatment services to DOC inmates in MSCF and EMCF. Vendor and SUD Program may be used interchangeably in the document, but have the same meaning.]

a) Outpatient (“OP”) – provides regularly scheduled individual, group and/or family counseling for less than nine hours per week. Approximates American Society of Addiction Medicine (“ASAM”) Level I.

b) Intensive Outpatient (“IOP”) – provides a range of treatment sessions and services, including clinical intensive substance use disorder (“SUD”) counseling and psycho-education (didactic) sessions. Services are provided in a structured environment for a minimum of nine hours of counseling per week. Approximates ASAM Level II.1.

c) Short-term residential (“STR”) – primarily designed to address specific addiction and living skills problems through a prescribed twenty-four hour per day activity regimen on a short-term basis. Clients reside together and are not commingled with other inmates (e.g. general population) who are not admitted to SUD treatment programming. Approximates ASAM Level III.7 treatment services (medically monitored intensive inpatient treatment).

d) Long-term residential (“LTR”) – primarily designed to foster personal growth and social skills development, with intervention focused on reintegrating the inmate into the greater community, and where education and vocational development are emphasized. Clients reside together and are not commingled with other inmates (e.g. general population) who are not admitted to SUD treatment programming. Approximates ASAM Level III.5 treatment modality (clinically managed, high intensity).

B. Admission and Assessment Requirements

1. Vendor shall perform SUD assessment of inmates referred by Classification staff to the vendor for a full SUD assessment. (DOC classification will refer inmates who have been screened for the presence of a SUD and meet medium level of custody security status.) In order to conduct the full SUD assessments, the vendor shall either station qualified staff on-site at Intake facilities or have mobile staff capability. The SUD assessment must take place within 5 days of the inmate’s screening referral.

2. All inmate assessments shall result in a Diagnostic and Statistical Manual (“DSM”) diagnosis and document ASAM level of care determination for purposes of an inmate’s placement in the clinically appropriate and corresponding treatment program (OP, IOP, STR or LTR).

3. Vendor shall use a SAMHSA approved, evidence-based, validated assessment tool for a criminal justice population, such as the TCU: Correctional Residential Treatment-Initial Assessment form.

a) The comprehensive assessment tool must assess medical status, employment and support, tobacco, drug and alcohol use, legal status, family status, social status, readiness for change, psychiatric status, including diagnosis, as well as behavioral risk factors for HIV and Hepatitis.

4. For admission to the SUD treatment program, the inmate must meet DSM-5 and ASAM criteria for the identified LOC placement. For example:

a) If an inmate meets DSM-5 and ASAM criteria for placement in a short-term residential level of care, then the inmate will be admitted to the SUD treatment program vendor’s short-term residential program.

b) If an inmate meets DSM-5 and ASAM criteria for placement in a long-term residential level of care, then the inmate will be admitted to the SUD treatment program vendor’s long-term residential program.

c) If an inmate meets DSM-5 and ASAM criteria for placement in an outpatient level of care, then the inmate will be admitted to the SUD treatment program vendor’s outpatient program or another licensed SUD treatment program at an alternate location.

d) If an inmate meets DSM-5 and ASAM criteria for placement in an intensive outpatient level of care, then the inmate will be admitted to the SUD treatment program vendor’s intensive outpatient program or another licensed SUD treatment program at an alternate location.

5. For those inmates who are assessed by the vendor based upon a Classification referral at Intake, but do not meet clinical standards for placement in outpatient or residential treatment programming, the vendor shall re-assess the inmate on a periodic basis to determine current need for treatment. The DOC may require the vendor to provide mobile staff to perform re-assessment of inmates at various DOC locations or may select to move the inmate to vendor staff locations.

6. If an inmate, who is clinically appropriate for admission to either outpatient or residential treatment, is excluded from admission to the SUD treatment program because of security classification and/or behavior, the vendor shall re-assess the inmate on a periodic basis to determine current need for treatment and any prior barriers to admission will be re-evaluated by DOC. The DOC may require the vendor to provide mobile staff to perform re-assessment of inmates at various DOC locations or may select to move the inmate to vendor staff locations.

C. Client care and programming

1. Treatment Plan and Planning

a) Treatment Plan

i. The vendor shall establish a client treatment plan that is specific, measurable and outcomes-focused for every client, which shall be developed based on assessments made of the client.

ii. The vendor shall initiate development of a measurable client treatment plan upon the client’s admission, and shall enter the client’s treatment plan into the client record at least three days following admission, not to exceed fifteen days.

iii. The client’s treatment plan and client treatment progress shall be reviewed by the treatment team at least every sixty days, with such review and revisions, if any, documented in the client’s clinical record.

iv. The treatment plan shall address, at a minimum, the following life domains: substance use disorder, legal issues, educational skills, physical health and recreational skills. In addition, the treatment plan shall incorporate other DOC programming related to other areas of concern, including, but not limited to, any criminogenic programming.

b) Treatment Planning and Continuity of Care

i. Vendor social work staff shall consult with appropriate DOC or other contracted staff to coordinate treatment planning and ensure continuity of care.

ii. Vendor program staff shall provide or coordinate the following supportive services for each client as appropriate to the client’s treatment plan:

· Vocational and educational counseling and training;

· Legal services rendered by an attorney, licensed or otherwise authorized to practice law in this State, when such services are related to the client’s treatment;

· Job placement for clients whose plans of care indicate a need for such services;

· Housing resources; and

· Name, address and telephone numbers of offices where information concerning Medicaid coverage may be obtained.

iii. The vendor shall maintain a directory of client referral resources, such as housing, child care and social services, to be made available for use by staff and clients.

2. Counseling and Didactic Education

a) Every client shall be assigned to a primary SUD treatment counselor at admission.

b) Counseling means the utilization of special skills and evidence-based practices to assist individuals, families, significant others and/or groups to identify and change patterns of behavior relating to SUD that are maladaptive, destructive and/or injurious to health through the provision of individual, group and/or family therapy by licensed or certified professionals or approved counselors-intern. Counseling does not include didactic education, lectures and/or self-help support groups, such as Alcoholics Anonymous, Narcotics Anonymous or similar twelve-step programs/facilities.

c) The vendor must be capable of increasing frequency of individual client counseling sessions based on a client’s clinical needs.

d) Group counseling sessions:

i. do not include educational or family counseling sessions; and

ii. shall not exceed an average of twelve clients and shall not exceed fourteen clients in any one session. This does not apply to educational or family counseling sessions.

e) Didactic education means a structured treatment intervention designed to instruct or teach clients about topics related to SUD and treatment related issues.

i. Client didactic education shall be provided with respect to the client’s diagnosis, the disease of addiction, risk of exposure to AIDS/Hepatitis, other health consequences of substance use and dependence, relapse prevention, family issues related to substance use, needs of clients with co-occurring disorders and issues such as domestic violence, parenting and sexual abuse.

ii. Didactic education and structured activities may commingle inmates in different ASAM levels of treatment.

f) For the levels of care identified, counseling, didactic education and structured activities must meet the requirements listed below.

i. OP

· Each client must receive individual, group and/or family counseling for less than nine hours per week. These hours shall include a minimum of one monthly individual client counseling session and group counseling, family counseling and didactic education sessions as determined by the treatment plan.

ii. IOP

· Each client must receive a minimum of nine hours of counseling per week consisting of a minimum of one individual client counseling session per week and a minimum of eight hours of group counseling, family counseling and didactic education sessions per week.

iii. STR

· Each client must receive at least twelve hours of counseling per week on at least six separate occasions. The twelve hours shall include a minimum of one hour of individual client counseling and ten hours of group counseling.

· Client didactic education shall be provided for at least eight hours per week.

· Clients must spend at least seven hours each day in structured activities to include individual and/or group counseling sessions, didactic education, life skills training, vocational training/activity, recreation, self-help meetings and criminogenic programming.

iv. LTR

· Each client must receive at least eight hours of counseling per week on at least five separate occasions. The eight hours shall include a minimum of one hour of individual client counseling and seven hours of group counseling.

· Client didactic education shall be provided for at least three hours per week.

· Clients must spend at least seven hours each day in structured activities to include individual and/or group counseling sessions, didactic education, life skills training, vocational training/activity, recreation, self-help meetings and criminogenic programming.

3. Co-occurring Services

a) The vendor shall screen for co-occurring disorders and either treat or refer those clients in need of co-occurring services.

i. A co-occurring disorder means the co-occurrence of substance-related and mental disorders as described by the DSM, in which the substance use and mental health disorders are primary.

b) The vendor providing SUD treatment to clients diagnosed with co-occurring disorders shall have clearly written policies and procedures governing the integrated treatment of substance use and mental health treatment (screening, assessment, diagnosis and service provision including referrals to mental health agencies and integrated treatment plans) or individuals diagnosed with co-occurring disorders.

ii. Policies and procedures shall include the qualifications of clinical and medical staff responsible for screening, assessing and diagnosing clients with co-occurring disorders and providing treatment and medical services to such clients.

· Only licensed individuals whose licensure scope of practice allows them to render a DSM diagnosis for both mental health and SUD may assess and diagnosis clients with co-occurring disorders.

iii. The vendor shall ensure that clinical supervision is provided by staff possessing clinical credentials necessary to provide clinical supervision to staff rendering treatment and services to clients diagnosed with co-occurring disorders.

iv. The vendor shall develop policies and procedures for developing and maintaining affiliation agreements, case consultation, coordination and referral mechanism to mental health treatment services in order to facilitate the provision of integrated treatment service.

v. The vendor’s SUD treatment program director shall ensure that the client treatment plan addresses both the client’s co-occurring disorders.

4. Medication Assisted Treatment

a) If a client is admitted while pursuing medically assisted treatment, the vendor shall support, or, at a minimum, not interfere with, the client’s medically assisted treatment.

5. Other programming

a) Existing educational, vocational, and criminogenic-based programming shall be available at MSCF and EMCF in order to be included as part of the structured activity required for SUD treatment programming. (Current examples include Living in Balance and Engaging the Family.)

D. Staff

1. Credentials/Qualifications and Supervision

a) Statewide Director of SUD Treatment Program - The vendor shall employ one Statewide Director of SUD Treatment Program to oversee all contractual obligations of the vendor staff and serve as liaison to DOC.

i. Statewide Director Qualifications – The Statewide Director must have at least one year experience working with a criminal justice population and meet at least one of the following qualifications:

· Be a NJ licensed psychologist with at least five years of experience in addiction services, two of those years in a supervisory capacity, who possesses a Certification of Proficiency in the Treatment of Alcohol and other Psychoactive substance use disorders from the American Psychological Association, College of Professional Psychology, or is a Certified Clinical Supervisory by the Addictions Professionals Certification Board of New Jersey (APCBNJ);

· Be a NJ licensed clinical social worker with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a certified clinical supervisory by the APCBNJ;

· Be a NJ licensed professional counselor, or licensed marriage and family therapist, with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a certified clinical supervisory by the APCBNJ;

· Be a NJ LCADC with at least five years of experience in addiction services, two of those years in a supervisory capacity, who in addition holds a clinical Master’s degree recognized by the State Board of Marriage and Family Therapy Examiners, Alcohol and Drug Committee, Division of Consumer Affairs, NJ Department of Law and Public Safety;

· Be a NJ licensed physician with at least two years of supervisory experience in addiction services and who is certified by the American Society of Addiction Medicine, or is a Board-certified psychiatrist;

· Be a NJ licensed advanced practice nurse with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a clinical supervisor certified by the APCBNJ; or

· Have a doctoral degree in human services, mental health or social work with at least two years of supervisory experience

ii. Statewide Director Responsibilities – The Statewide Director’s responsibilities shall include the following:

· Providing administrative oversight of the SUD treatment program;

· Ensuring the development, implementation and enforcement of all policies and procedures as required under this chapter, including client rights;

· Planning and administration of all operational functions including managerial, personnel, fiscal and reporting requirements of the SUD treatment program;

· Developing an organizational plan and ensuring that services are consistent with the organization’s mission, while monitoring their effectiveness;

· Establishing and implementing a formal quality assurance program that is comprehensive and integrated with the program’s quality assurance plans and programs; address all levels of treatment programming and client care; ensure that all personnel are assigned duties based upon their education, training, competencies and job description; while utilizing written, job-relevant criteria to make evaluation, hiring and promotional decisions;

· Selecting and hiring responsibility for all program staff, as well as participating in the determination of staffing issues including, but not limited to, establishing and maintaining policies ensuring references, credentials and criminal history background checks of all prospective staff and making certain that they have been reviewed and verified; developing written policies regarding the employment of family members, past and present governing body members and volunteers; developing written policies regarding hiring staff with past criminal convictions and/or ethical violations that ensure that the convictions/violations do not impact staff ability to perform duties; and developing policies for assessing staff performance, determining employment and termination decisions;

· The director shall advise candidates and staff members that candidates and staff members must disclose to him/her any disciplinary outcome imposed as a result of an investigation by any State licensing agency, law enforcement agency or professional disciplinary review board, such as disciplinary probation, suspension of license, revocation of license or criminal conviction at the time of initial employment and/or during employment if the action occurs after hire.

· Ensuring the provision of timely staff orientation, education and supervision;

· Establishing and maintaining liaison relationships and communication with DOC staff, other contracted staff, service providers, support service providers, community resources and clients;

· Overseeing the development and implementation of policies and procedures, in conjunction with designated staff members, for the various services provided;

· Implementing and monitoring the quality of all services provided by the program, including the review of program outcomes;

· Ensuring that designated SUD program space is maintained in a safe and sanitary condition to ensure client and staff safety;

· Ensuring that any plans of correction, licensing deficiencies and complaint reports are addressed as specified by the DOC, licensing agency or other requesting entity;

· Developing and implementing client safety policies and procedures that include, but are not limited to, forbidding staff to engage in client coercion, sexual harassment and sexual relationships with clients;

· Developing, implementing and providing administrative oversight of a volunteer services program, if such a program is utilized;

· Ensuring that there are policies and procedures in place so that only those DOC inmates screened, assessed and identified as having a SUD are admitted to the SUD treatment program for treatment, if necessary; and

· Providing clinical supervision to the Program Directors in accordance with clinical supervision requirements of any and all applicable state agencies and boards.

b) Directors of SUD Treatment Program - The vendor shall employ one Director of SUD Treatment Program at MSCF and one Director of SUD Treatment Program at EMCF.

i. Director Qualifications – The Director must have at least one year experience working with a criminal justice population and meet at least one of the following qualifications:

· Be a NJ licensed psychologist with at least five years of experience in addiction services, two of those years in a supervisory capacity, who possesses a Certification of Proficiency in the Treatment of Alcohol and other Psychoactive substance use disorders from the American Psychological Association, College of Professional Psychology, or is a Certified Clinical Supervisory by the Addictions Professionals Certification Board of New Jersey (APCBNJ);

· Be a NJ licensed clinical social worker with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a certified clinical supervisory by the APCBNJ;

· Be a NJ licensed professional counselor, or licensed marriage and family therapist, with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a certified clinical supervisory by the APCBNJ;

· Be a NJ LCADC with at least five years of experience in addiction services, two of those years in a supervisory capacity, who in addition holds a clinical Master’s degree recognized by the State Board of Marriage and Family Therapy Examiners, Alcohol and Drug Committee, Division of Consumer Affairs, NJ Department of Law and Public Safety;

· Be a NJ licensed physician with at least two years of supervisory experience in addiction services and who is certified by the American Society of Addiction Medicine, or is a Board-certified psychiatrist;

· Be a NJ licensed advanced practice nurse with at least five years of experience in addiction services, two of those years in a supervisory capacity, who is a clinical supervisor certified by the APCBNJ; or

· Have a doctoral degree in human services, mental health or social work with at least two years of supervisory experience.

ii. Director Responsibilities – The Director’s responsibilities shall include, but not be limited to, the following:

· Developing and maintaining written objectives, policies and procedures, an organizational plan and a quality assurance program for SUD counseling services that are reviewed by the Statewide Director;

· Ensuring that behavioral and pharmacologic approaches to treatment are evidence-based or based on universally accepted information to provide treatment services consistent with recognized treatment principles and practices for each level of care and type of client served by the program;

· Ensuring that clinical supervision requirements for staff including, but not limited to, counselor-interns are provided in accordance with clinical supervision requirements of any and all applicable state agencies and boards and that clinical staff including, but not limited to, counselor-interns are supervised by the appropriately credentialed staff. This includes, but is not limited to:

· directly providing clinical supervision to staff and/or ensuring that direct clinical supervision is provided by a staff person who meets the qualifications specified by and recognized as direct clinical supervision pursuant to the rules of the State Board of Marriage and Family Therapy Examiners, Alcohol and Drug Committee, Division of Consumer Affairs, NJ Department of Law and Public Safety; and

· providing and documenting that direct clinical supervision is provided at least one hour per week to all clinical staff, individually or in a group setting, with group supervision not to exceed fifty percent of supervision time;

· Ensuring that SUD counseling services are provided as specified in the client treatment plan and coordinated with other client care services, if applicable, in order to provide continuity of care;

· Ensuring that assessment, diagnosis and treatment of clients with co-occurring disorders are provided by appropriately trained and qualified clinical staff and that clinical supervision of such staff is provided;

· Assisting in developing and maintaining written job descriptions for SUD counseling personnel and assigning duties;

· Assessing and participating in staff education activities and providing consultation to program personnel;

· Providing orientation to and evaluation of new counseling staff prior to assigning them counseling responsibilities;

· Ensuring that all counseling staff are properly licensed and/or credentialed;

· Participating in the identification of quality care indicators and outcome objectives and the collection and review of data to monitor staff and program performance; and

· Participating in planning and budgeting for the provision of SUD counseling services.

c) Staff

i. The vendor must ensure that the ratios of SUD counseling staff are maintained so that 50 percent of the staff are licensed clinical alcohol and drug counselor (“LCADC”) or certified alcohol and drug counselor (“CADC”) or other licensed clinical professionals doing work of an alcohol and drug counseling nature within their scope of practice. The remaining 50 percent of SUD counseling staff shall be designated as alcohol and drug counseling-interns or credentialed-interns (formerly referred to as “substance abuse counselors in training”) who are actively working toward their LCADC or CADC status, or toward another NJ clinical license that includes work of an alcohol and drug counseling nature within its scope of practice. Counselor-interns may be actively working toward their LCADC or CADC status for no more than three years. The Director must maintain an active client caseload if the Director is to be counted in the above ratios.

· Each SUD counselor shall be either an LCADC or CADC or another licensed health professional doing work of an alcohol and drug counseling nature within their scope of practice.

· A CADC must work under the supervision of an LCADC or another NJ licensed clinical professional designated as a qualified clinical supervisor per N.J.A.C. 13:34C-6.2.

· A CADC cannot diagnose substance abuse.

· SUD counseling staff without an LCADC or CADC status or who do not possess another NJ clinical professional license that includes work of an alcohol or drug counseling nature within their scope of practice shall function as alcohol and drug counselor-interns or credential-interns and shall:

· Be enrolled in a course of study leading to a CADC or LCADC, or another NJ clinical professional license that includes work of an alcohol and drug counseling nature within its scope of practice, without regard to changes in employment, with progress towards certification or licensing on file, reviewed by the program at least semi-annually and documented; and

· Be trained, evaluated and receive continuing formal clinical supervision by the Director or designee, pursuant to the clinical supervision rules (N.J.A.C. 13:34C) of the State health professional licensing board for the course of study in which they are enrolled.

ii. Only staff possessing the appropriate clinical background and educational qualifications from the appropriate clinical discipline may provide the diagnosis, assessment and treatment of clients with co-occurring disorders.

2. Staffing ratios. The vendor shall maintain an average ratio of SUD treatment counselors to clients on the basis of each program’s daily census as follows:

a) OP – 1:35

b) IOP – 1:24

c) STR – 1:8

d) LTR – 1:12

E. Discharge planning

1. The vendor shall initiate discharge/continuum of care planning for each client upon admission.

a) Goals for discharge shall be incorporated in the client’s treatment plan upon admission to the program and shall address problems identified at admission and during treatment.

vi. Such goals shall be shared with the SUD program counselor staff and supervisor and be routinely reviewed and assessed with the client and the client’s treatment team.

b) The client, his/her family or legally authorized representative, unless family participation is refused or contraindicated, shall participate in developing the discharge/continuum of care plan.

2. The vendor shall establish and implement staff educational services regarding discharge/continuum of care planning.

3. The vendor SUD treatment program social work staff shall consult with appropriate DOC or other contracted staff to coordinate discharge planning for clients being discharged from the SUD treatment program into the general population or being discharged from the SUD treatment program into the community in order to ensure referrals, including, but not limited to, social service agencies for housing, Medicaid and other assistance. This consultation shall be documented in the client progress notes.

4. The vendor shall include education of the client and his/her family, if applicable, or legally authorized representative as part of its discharge/continuum of care planning service and shall provide information regarding the following:

a) The availability of support groups and referrals, when appropriate, to programs including, but not limited to, AA, Narcotics Anonymous, Nar-Anon, Al-Anon and Alateen.

b) The symptoms, effects and treatment of SUD;

c) Codependency and its effect on the treatment of SUD; and

d) Implementation of self-care rehabilitation measures following discharge.

F. Policies and procedures – The vendor shall establish and maintain policies and procedures as set out below, and submit them to DOC.

1. Policy and Procedure Manual

a) The vendor must have a policy and procedure manual about the organization and operation of the SUD treatment program, which shall contain the following:

i. program vision and mission statement;

ii. staffing patterns and definitions of “full-time” and “shift”;

iii. description of services and hours of operation (e.g. business hours);

iv. organizational chart;

v. description of the program’s quality assurance program;

vi. statement regarding program’s adherence to ensuring confidential maintenance of client records in accordance with federal and state confidentiality laws, including HIPAA and 42 C.F.R. Part 2;

vii. description of the modalities of treatment provided, including a listing of services, procedures and ASAM level of care designations performed;

viii. description of policies and procedures regarding the use of sanctions in the program;

ix. policies and procedures describing the coordination of care and/or referral of clients with co-occurring substance use and mental health disorders;

x. policies addressing the program’s handling of illicit substances, alcohol, weapons and other prohibited items or materials from within the program, which is consistent with DOC policies;

xi. policies and procedures describing the delivery of service, including, but not limited to, the frequency of counseling interventions and didactic sessions, weekly and monthly written schedules of all program activities, and content of didactic sessions, including a written description or curriculum of didactic sessions offered; and

xii. policies related to hiring and staffing including, but not limited to:

· ensuring references, credentials and criminal history background checks of all prospective staff and review/verification procedures;

· employment of family members, past and present governing board members and volunteers;

· hiring of staff with past criminal convictions and/or ethical violations to ensure that convictions/violations do not impact staff ability to perform duties; and

· assessment of staff performance and determining employment and termination decisions.

b) The policy and procedure manual must be maintained on-site and be available for review by clients, staff and the public.

c) The policy and procedure manual must be reviewed annually by the program director and any governing authority.

2. Client Care Policies and Procedures

a) The vendor shall establish and maintain client care policies and procedures, which shall be reviewed on an annual basis.

b) All client care policies and procedures shall be sensitive to cultural, religious, ethnic, age, and gender issues.

c) Client care policies and procedures shall facilitate continuity of care and client safety and include, at a minimum, the following:

i. admissions and exclusionary criteria, including identification of the conditions or diagnoses eligible and ineligible for admission;

ii. client orientation process;

iii. services offered including, but not limited to, screening, assessment, diagnosis, counseling, education and case management;

iv. client rights;

v. staffing patterns;

vi. referral of clients to healthcare providers outside of the program and other treatment programs along the continuum of care;

vii. emergency care of clients;

viii. informed consent requirements;

ix. initiation, implementation, review and revision of a written treatment plan of care to include DSM diagnosis, ASAM level of care assessment, measurable goals, objectives and treatment outcomes;

x. criteria for discharge, involuntary discharge, transfer and re-admission of clients;

xi. drug screening;

xii. reporting of critical incidents, complaints and threats; and

xiii. development and implementation of client safety policies and procedures including, but not limited to, forbidding staff from engaging in client coercion, sexual harassment and sexual relationships with clients.

3. Client Rights

a) Written policies and procedures regarding the rights of clients, including appeals procedures for involuntary discharge, shall be established, conspicuously posted and be available to clients, staff and the public.

b) Training on client rights policies and procedures shall be provided to staff annually and as part of new employee orientation.

c) The SUD treatment program shall comply with any applicable federal and state laws concerning client rights.

4. Discharge/Continuum of care planning

a) The vendor shall establish and implement written policies and procedures for discharge/continuum of care planning services, which shall address at least the following:

i. The staff responsible for planning, providing, and/or coordinating discharge/continuum of care planning services, including:

· Making referrals to community agencies (for example, mental health agencies, housing agencies) and resources for clinically appropriate services in the continuum of care; and

· Promoting and facilitating the continuing involvement of clients with support groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), following discharge;

ii. Documentation of discharge/continuum of care planning in the treatment plan, and including accompanying supervision;

iii. Use of the treatment team in discharge/continuum of care planning;

iv. The criteria for client discharge;

v. Description of the methods of client, and family involvement, where clinically appropriate, in developing the discharge/continuum of care plan; and

vi. Coordination and handling of treatment and referrals to ensure continuity of care for clients who are:

· Discharged/released to general population;

· discharged/released into the community, including to own/family housing, release with parole supervision or to a halfway house facility;

· inmates who are returned to SUD treatment programming from general population in order to resume or obtain additional (e.g. relapse/recovery) SUD treatment programming.

5. Clinical Records

a) The vendor shall establish policies and procedures to:

i. protect clinical records against loss, tampering, alteration, destruction, unauthorized use or other release of information without the client’s written consent;

ii. specify the period of time, not to exceed thirty days, within which the clinical record shall be completed following client treatment or discharge;

iii. regarding the transfer of the client’s clinical record information to another health care or treatment program/facility;

iv. ensure compliance with HIPAA and 42 C.F.R. Part 2 regarding providing copies of the client’s clinical record to the client, his/her legally authorized representative or the DOC where permitted by law or authorized in writing by the client.

G. Clinical Records and Confidentiality

1. The vendor shall establish a clinical record for each client. A clinical record means all records in the program pertaining to the client’s care.

2. The vendor shall document all services provided and transactions regarding the client in his/her clinical record in a uniform manner.

3. The clinical record shall include, at a minimum, the following:

a) Client identification data, including name, date of admission, address, date of birth, race, religion (optional), gender;

b) Admission, discharge and other reports, as required;

c) Client’s signed acknowledgment that he/she has been informed of and received a copy of client rights;

d) Summary of admission interview, and a copy of the assessment;

e) Client treatment plan, signed and dated by staff, as required, and documentation of client’s participation in the development of his/her treatment plan;

f) Clinical notes, weekly summary notes and progress notes;

g) Medications;

h) Record of referrals to other health care and social service providers;

i) Any signed, written informed consent forms; and

j) Discharge/continuum of care plan and discharge/continuum of care summary

4. The vendor shall maintain all clinical records and components thereof on-site at all times.

5. The clinical record shall be maintained by the SUD program and be kept separately and distinct from any DOC records and/or DOC medical vendor records.

6. The vendor shall ensure all client records and information are maintained and kept confidential in accordance with any and all applicable federal and state confidentiality laws, including, but not limited to, HIPAA and 42 C.F.R. Part 2.