Sec.17-226d-8. Long term care and rehabilitation programs

(a) Hours of operation — Each program shall operate 24 hours per day, seven days per week.

(b) Admission criteria

(1) Each program shall have and utilize written admission criteria which shall be available to service recipients, staff, the community and the Commission.

(2) No person shall be admitted to a program unless he meets the program's admission criteria and any person who is ineligible because he does not meet the admission criteria shall be referred elsewhere.

(3) The written admission criteria shall include, but need not be limited to consideration of the following factors:

(A) age

(B) sex

(C) physical health

(D) mental status

(E) previous treatment history

(F) history of alcohol abuse

(G) current use of alcohol

(4) No person may be admitted to the program who does not have a documented past and current history of multiple admissions to alcohol abuse or alcoholism treatment facilities.

(5) Program shall not exclude any service recipient from readmission who has had occasional lapses in sobriety so long as the service recipient is sober at the time of admission.

(c) Intake procedure

(1) Each program shall have and utilize a written intake procedure which shall include but need not be limited to:

(A) A procedure for making and accepting referrals pursuant to the requirements of section (g) of this regulation.

(B) A time limit within which initial assessment of service recipients admitted to the program will be completed.

(C) A procedure for determining whether or not the service recipient meets the program's admission criteria and is appropriate for the program.

(2) Each program shall, during the intake procedure, collect at least the following demographic information on a standardized form from each person seeking admission to the program:

(A) Name

(B) Home Address

(C) Telephone Number

(D) Date of Birth

(E) Sex

(F) Race/Ethnicity

(G) Marital and Family Status

(H) Employment Status and Employer

(I) Education

(J) Current Family Income

(K) Next of Kin

(L) Social Security Number

(M) Criminal Justice System Status

(N) Referral Source

(O) Insurance Coverage

(P) Date of Initial Contact

(Q) Date of Interview

(R) Signature and Title of Intake Worker

(3) Each service recipient history shall be completed by a member of the program's treatment staff and shall include, but need not be limited to the following information:

(A) presenting problem

(B) history of substance abuse and problems

(C) family and personal history

(D) education and employment history

(E) medical history

(F) history of arrests and convictions

(G) previous treatment history

(d) Orientation

(1) Each person admitted to a program shall receive an orientation in accordance with a written orientation policy and procedure.

(2) Such orientation shall include, but need not be limited to explaining in language understandable to each service recipient:

(A) the program's philosophy, goals and objectives;

(B) the services offered by the program;

(C) the program's hours of operation;

(D) the fee policy, fee schedule and that no person shall be denied services because of his inability to pay for such services;

(E) service recipient's rights;

(F) the program's expectations of the service recipient;

(G) the protection and restrictions which derive from the federal confidentiality requirements;

(H) the program's rules and procedures and the consequences of infractions of such rules; and,

(I) the program's termination and discharge procedures.

(e) Assessment procedure

(1) Each program shall have and utilize a written policy and procedure for assessing all persons admitted to the program. At a minimum the assessment shall include a written synthesis of information obtained during the intake procedure, which synthesis shall identify the service recipient's strengths and the staff person's observations of the service recipient's personality functioning and those situational factors which have contributed to the service recipient's current dysfunction.

(2) The assessment shall be used as a guide to the formulation of the service recipient's service plan.

(f) Service plan

(1) Each program shall prepare an individualized, written plan which states the service recipient's problems and describes the services to be provided by the program to address the problems related to, or resulting from, the service recipient's alcoholism.

(2) Each service plan shall be reviewed periodically for completeness and appropriateness in accordance with a written standardized policy and procedure designed to ensure that the plan remains applicable to the changing needs of the service recipient. The service recipient's records shall contain written evidence of such periodic review, assessment of the service recipient's progress and any revisions that have been made in the plan as a result of the review.

(g) Referrals

(1) Each program shall have and utilize a written policy and procedure for service recipient referrals as part of a comprehensive network of care. Such policy shall include, but need not be limited to:

(A) a description of the circumstances or conditions under which a referral shall be made, accepted or rejected;

(B) procedures for referral of service recipients between specific components of the awardee's program; and,

(C) current information on, and referrals to, self-help groups.

(h) Service recipient records

(1) Each program shall use a standardized record-keeping system and shall maintain an individualized record for each service recipient admitted to the program which shall document the changing status, needs and activities of the service recipient. Such record shall include, but need not be limited to:

(A) all standardized statistical information as required by section (c) of this regulation and emergency information;

(B) all parts of the service recipient's individualized service plan as required by section (f) of this regulation;

(C) all assessments of the service recipient performed by program staff, including documentation of the service recipient's problems and needs;

(D) the results of all physical, psychological, medical, laboratory and vocational examinations and tests including the signature and title of the person who administered the test or performed the examination;

(E) a weekly summary of the service recipient's activities as listed in the service plan; and,

(F) a discharge summary for each service recipient who has left the program.

(2) All active records shall be kept in locked files in a secured room.

(3) Each program shall have and utilize a policy and procedure for closing and storing service recipient records. The policy and procedure shall include, but need not be limited to the following provisions:

(A) the entire record shall be maintained for a period of at least five years after closure and shall be protected against loss, damage, or breach of confidentiality;

(B) after five years such records may be destroyed by shredding or burning; and,

(C) the policy shall specify under what circumstances a record is to be closed.

(i) Medical services and medication

(1) Each program shall ensure that each person admitted to the program shall have a complete medical history and physical examination.

(2) Each program shall have and utilize a written policy and procedure for administering, storing and self administration of all medications. All medications shall be marked, regularly inventoried and stored in a locked cabinet.

(3) Each program shall have a fully equipped first aid kit on the premises at all times the program is in operation.

(4) When a service recipient is referred from another program and there is no break in the treatment regimen, a physical examination as required by subsection (1) above need not be repeated by the program accepting the referral. A record of the physical examination from the referring program shall be included in the intake information recorded in the service recipient's record.

(j) Staffing

At least one paid member of the program's staff shall be on duty during the night.

(k) Meals

Each program shall provide at least three nutritionally balanced meals for each service recipient each day.

(Effective September 20, 1984)