14 CRR-NY 816.5NY-CRR
14 CRR-NY 816.5
14 CRR-NY 816.5
816.5 Standards applicable to all withdrawal and stabilization services.
(a) Screening, linkages and referral.
(1) All providers of withdrawal and stabilization services must provide screening, linkages and referral to other appropriate providers of physical and behavioral health services if such services cannot be provided by the withdrawal and stabilization program.
(2) All providers must develop referral sources and keep updated lists of regional programs which provide treatment and recovery services at all levels of care.
(b) Policies and procedures.
(1) Providers of withdrawal and stabilization services must develop and implement written policies and procedures approved by the program sponsor. Such policies and procedures must include, at a minimum, the following:
(i) use of standardized withdrawal evaluation instruments;
(ii) staffing for sufficient coverage and task designation; at lease 50 percent of all clinical staff must be qualified health professionals as defined in Part 800 of this Title;
(iii) screening and referral for physical conditions and/or mental disabilities;
(iv) infection control;
(v) procedures for public health education and screening with regard to tuberculosis, sexually transmitted diseases, hepatitis, and HIV prevention and harm reduction;
(vi) procedures for the coordination of care with other service providers including transfers, emergency care and patient transport;
(vii) quality assurance and utilization review procedures;
(viii) medical and nursing procedures consistent with professional practice;
(ix) admission and planning for level of care transitions;
(x) pharmacological services including storage and dispensing medication pursuant to applicable State and Federal regulations and ensuring appropriate continuation of medications prescribed to the patient prior to admission;
(xi) laboratory testing protocols;
(xii) records and reporting;
(xiii) incident reporting;
(xiv) screening of patients and visitors and the disposal of contraband;
(xv) compliance with other applicable Federal and State regulations and office guidance.
(c) Co-location.
(1) Chemical dependence withdrawal and stabilization services may be co-located with other chemical dependence services to ensure improved coordination of care and linkage.
(2) Patients enrolled in a medically monitored withdrawal and stabilization service may participate in another level of care if clinically and medically appropriate.
(d) Capacity.
Capacity approved by the office may not be exceeded at any time except with written permission from the office.
(e) Admission.
(1) Admission shall be based upon a diagnosis of substance use disorder pursuant to the most recent edition of either the Diagnostic and Statistical Manual of the American Psychiatric Association, or the International Classification of Diseases.
(2) A level of care determination must be made using the OASAS level of care assessment tool as defined in Part 800 of this Title and documented in the patient record.
(3) Medication policies must ensure the appropriate continuation of medically appropriate and lawfully prescribed medication taken by the patient prior to admission.
(4) Each person admitted to the withdrawal and stabilization service must receive a medical evaluation as soon as possible, but no later than the first 24 hours.
(5) A provider of withdrawal and stabilization services may provide maintenance on opioid agonist medications while a patient is being detoxified from other substances and/or tapering from such agonist medications, provided the program administering such service meets all Federal and State requirements which regulate the use of approved opioid full agonist treatment.
(6) All admissions shall be consistent with Part 815 of this Title. Admission is voluntary and a patient shall be free to discharge themselves from the service at any time, provided however, this provision shall not preclude or prohibit attempts to persuade a patient to remain in the service in their own best interest.
(i) Any person who desires to leave the service should be offered an examination as soon as possible by medical personnel of the service.
(ii) If the medical personnel determine upon examination that such person is incapacitated by alcohol and/or substances to the degree that they may endanger themselves or other persons, or that there is an acute need for medical or psychiatric intervention, a referral must be made to a provider designated by the office to provide emergency services pursuant to section 22.09 of the Mental Hygiene Law or to another appropriate provider.
(f) Initial services; initial evaluation.
(1) Except as otherwise provided in paragraph (2) of this subdivision, an initial evaluation must be conducted by a clinical staff member. In addition to patient identifying and emergency contact information the following clinical and psycho-social information is required:
(i) withdrawal evaluation, including patient's history and recent use of alcohol and/or substances, treatment history, medical history, high risk behaviors, mental status and psychiatric history, living arrangements, level of self-sufficiency, supports, and barriers to treatment services; and
(ii) any information concerning a disability which may affect communication or other functioning.
(2) If the patient had previously been admitted to the same service within 30 days of the current admission, the previous evaluation may be utilized, provided it is appropriately updated.
(3) Except for patients admitted to a medically supervised outpatient service, no patient may be continued in the withdrawal and stabilization service longer than seven days after admission unless there is a reasonable probability that discharge criteria will be met within an additional seven days. Current evidence must document a level of instability requiring continued stay for adjustment of medication or attainment of a level of stability to enable functioning outside a structured setting; and either:
(i) there is medical evidence of moderate to severe organ damage related to alcohol and/or other substance use; or
(ii) the patient is pregnant and continued stay is necessary to insure stabilization and/or completed referral to continuing treatment; or
(iii) there is evidence of other medical complications warranting continued care in a withdrawal and stabilization service.
(g) Recovery/care plan.
(1) The plan must be completed within 24 hours of admission, and shall be based on the initial evaluation conducted. The plan shall:
(i) be developed in collaboration with the patient by the responsible clinical staff member(s) and signed and dated by all parties including the patient when completed and agreed upon;
(ii) provide goals for outcome of the treatment, the protocols to be followed for medical withdrawal and the care to be provided;
(iii) be updated as appropriate and as required by the level of care should additional problems requiring immediate treatment be identified;
(iv) reflect coordination of medical and/or psychiatric care, and/or the provision of other services provided concurrently either directly or through a secondary provider; and
(v) be incorporated in the patient’s case record along with written orders, prescriptions and the provision of withdrawal and stabilization services.
(2) Review of recovery/care plan. All components of the recovery/care plan shall be reviewed by the responsible clinical staff as often as necessary consistent with the level of care, and at least once in the first seven days; in the event that an individual's stay is extended beyond seven days, the entire recovery/care plan must be reviewed and modified accordingly every subsequent three days during the course of the extended stay. Revisions to the recovery/care plan shall be reflected in the patient's case record, signed and dated by the responsible clinical staff.
(3) Progress notes shall be written, signed and dated by clinical staff members; give a chronological picture of the patient's progress; and must be sufficiently detailed to delineate the course and results of the patient's progress in treatment.
(i) Unless additional requirements apply to specific levels of withdrawal and stabilization services, progress notes shall be documented no less often than once per shift for the first five days and no less often than once per day thereafter.
(ii) If a patient's condition necessitates more frequent documentation, the appropriate staff must document the provision of those services and/or care in the patient's case record.
(h) Discharge and planning for level of care transitions.
(1) Discharge planning shall commence upon admission and involve consultation with the patient; planning must provide a framework for a long-term, patient-driven recovery plan and link the patient to appropriate level of care transition services to support the plan; and include detailed information on referral and plan specifics. Except for unplanned discharges, no patient shall be discharged until the plan is complete and identifies a staff member assigned to follow up on referrals.
(2) The plan shall include, but not be limited to at least the following:
(i) an evaluation of the patient's living arrangement, level of self-sufficiency and available support systems;
(ii) identification of substance use disorder treatment and other services the patient will need after discharge including alternative medical and psychological providers; and
(iii) a list of current medications.
(3) A member of the clinical and medical staff who participated in preparing the plan shall sign and date the plan upon its completion. Except for medically monitored withdrawal and stabilization services, the program physician shall also sign and date the plan.
(4) The plan shall be given to the patient upon discharge and with appropriate patient consent, the care plan, including level of care transition planning, shall be forwarded to any subsequent service providers. The patient and their family/significant other(s) shall be offered naloxone education and training and a naloxone kit or prescription.
(5) For a patient transitioning directly from a withdrawal and stabilization service to another service within the same facility, a transfer plan may take the place of a discharge plan. To ensure sufficient information is available to the new service, a transfer plan must include information about the patient's immediate needs, medical and psychiatric diagnoses, and plan for meeting those needs.
(i) Case records.
(1) Providers must keep individual case records for each patient admitted. These records must include, at a minimum, all information and documentation required in this Part, including but not limited to:
(i) evaluation at admission;
(ii) recovery care plan and all revisions including progress notes and discharge plan;
(iii) documentation of public health education and screening with regard to tuberculosis, sexually transmitted diseases, hepatitis, and HIV prevention and harm reduction;
(iv) documentation of contacts with a patients family and/or significant other(s); and
(v) signed releases of consent for information, if any.
(2) Patient records shall be maintained, shared with other staff involved in the treatment of a patient and with professional staff of other providers involved in the care of such patient, and released in accordance with State and Federal laws and regulations governing confidentiality.
(3) If the service denies admission due to lack of available capacity or resources, it shall provide a referral to the most appropriate available service.
(j) Utilization review and quality improvement.
Each withdrawal and stabilization service must have a utilization review process, a quality improvement process, and a written plan that identifies key performance measures for that particular program.
(k) Staffing.
(1) Staff may be either specifically assigned to the withdrawal and stabilization service or may be part of the staff of the facility within which the service is located, provided that:
(i) they have specific training in the treatment of substance use disorder; and
(ii) the service identifies and documents the percentage of time each shared staff member is assigned to each service.
(2) A withdrawal and stabilization service shall have regular, scheduled, and documented training made available in the following subject areas, or as determined by the office:
(i) substance use disorder and other addictive disorders;
(ii) signs and symptoms of withdrawal; and
(iii) complications of withdrawal; and
(iv) public health education and screening with regard to tuberculosis, sexually transmitted diseases, hepatitis, and HIV prevention and harm reduction.
(3) Each service shall have a qualified individual designated as the health coordinator to ensure the provision of education, risk reduction, counseling and referral services to all patients regarding HIV and AIDS, tuberculosis, hepatitis, sexually transmitted diseases, and other communicable diseases.
(4) Clinical staff shall have primary responsibility for implementing the care plan.
(5) Medical staff shall have primary responsibility for coordinating medical care including, but not limited to, physical examination, prescription, dispensing, and/or administration of medications, observation of symptoms, and vital signs and the provision of nursing care.
(6) Additional staffing requirements specific to the type of withdrawal and stabilization service provided pursuant to applicable sections of this Part.
14 CRR-NY 816.5
Current through May 31, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: JULY 31, 2023, is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Admisnistrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of the NYS Rules.