CHAPTER 711. STANDARDS FOR CERTIFICATION OF TREATMENT ACTIVITIES WHICH ARE A PART OF A HEALTH CARE FACILITY

Subchap. Sec.

A.    GENERAL PROVISIONS … 711.1
B.    APPROVAL PROCEDURES … 711.11
C.    STANDARDS FOR INTAKE EVALUATION AND REFERRAL ACTIVITIES … 711.41
D.    STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES—RESIDENTIAL TREATMENT AND REHABILITATION … 711.51
E.    STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES—SHORT-TERM DETOXIFICATION … 711.61
F.    STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES—TRANSITIONAL LIVING FACILITIES (TLFs) … 711.71
G.    STANDARDS FOR PARTIAL HOSPITALIZATION ACTIVITIES … 711.81
H.    STANDARDS FOR OUTPATIENT ACTIVITIES … 711.91
I.    [Reserved] … 711.101

Cross References

   This chapter cited in 28 Pa. Code §  704.1 (relating to scope); 28 Pa. Code §  705.1 (relating to general requirements for residential facilities); 28 Pa. Code §  705.21 (relating to general requirements for nonresidential facilities); 28 Pa. Code §  715.3 (relating to approval of narcotic treatment programs); 28 Pa. Code §  715.23 (relating to patient records); 31 Pa. Code §  89.621 (relating to inpatient detoxification services); 31 Pa. Code §  89.622 (relating to nonhospital, residential treatment and rehabilitation services); 31 Pa. Code §  89.623 (relating to outpatient services); and 58 Pa. Code §  15.7 (relating to disciplinary action).

Subchapter A. GENERAL PROVISIONS


Sec.


711.1.    Scope.
711.2.    Policy.
711.3.    Legal base.
711.4.    Exceptions.
711.5.    Revocation of exceptions.

§ 711.1. Scope.

 (a)  This chapter establishes the procedures for the issuance of a certificate of compliance for drug and alcohol treatment activities which are a part of a health care facility.

 (b)  This chapter also establishes the standards for the certification of compliance, under the act (71 P. S. § §  1690.101—1690.115), of drug and alcohol treatment activities which are part of a health care facility.

§ 711.2. Policy.

 (a)  Persons, partnerships, and corporations or other legal entities intending to operate a facility offering drug and alcohol treatment services within a health care facility shall first be issued a certificate of compliance.

 (b)  Drug and alcohol treatment activities which are a part of a health care facility are also subject to the licensure requirements for a health care facility under Part IV (relating to health facilities). The health care facility will receive a license issued by the Department, under the Health Care Facilities Act (35 P. S. § §  448.101—448.904) which will cover those drug and alcohol activities which are a part of a health care facility. The Department will also issue a certificate of compliance to the drug and alcohol component within the health care facility which will certify that program areas meet the minimum standards which are germane to drug and alcohol treatment under the act (71 P. S. § §  1690.101—1690.115). A health care facility which fails to meet the minimum standards may not be issued a certificate of compliance and a license issued by the Department shall exclude coverage of drug and alcohol activities. The application of the drug and alcohol program standards, in addition to the licensing standards under the Health Care Facilities Act, to drug and alcohol treatment activities within a health care facility, is necessary to insure that the same quality of services are maintained throughout drug and alcohol treatment activities within this Commonwealth.

 (c)  The program standards for license of free-standing drug and alcohol treatment facilities, and for certification of compliance of drug and alcohol treatment activities which are a part of a health care facility, are identical. If the general standards for drug and alcohol treatment activities are the same for a license under the Health Care Facilities Act and for a certificate of compliance under the act they have been deleted in this chapter to avoid a duplication of inspection.

 (d)  Health care facilities that provide the following drug and alcohol treatment activities shall comply with this subchapter and Subchapter B and then the specific subchapter that is applicable to that service. These treatment activities include intake, evaluation and referral, inpatient nonhospital, partial hospitalization, outpatient, and shelter. Health care facilities providing inpatient hospital drug and alcohol detoxification or treatment and rehabilitation services shall comply with Chapter 710 (relating to drug and alcohol services).

§ 711.3. Legal base.

 The authority of the Department to certify for compliance is established under the act.

§ 711.4. Exceptions.

 (a)  The Department may grant exceptions or extensions of time to this part when the policy objectives of this part are met, but no exception will be granted which contravenes the authorizing statute.

 (b)  The project director shall submit a written request for an exception which shall include the approval of the governing body.

 (c)  Exceptions may not be granted for a situation in which a provisional certificate of compliance would be appropriate.

§ 711.5. Revocation of exceptions.

 (a)  An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.

 (b)  In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.

 (c)  If a project wishes to request a reconsideration of a denial or revocation of an exception, it shall do so, in writing to the Department, within 30 days of receipt of the adverse notification.

Subchapter B. APPROVAL PROCEDURES


Sec.


711.11.    Application for certificate of compliance.
711.12.    Full certificate of compliance.
711.13.    Provisional certificate of compliance.
711.14.    Restrictions on certificate of compliance.
711.15.    Right to enter and inspect.
711.16.    Notification of deficiencies.
711.17.    Refusal or revocation.
711.18.    Hearings.

Cross References

   This section cited in 28 Pa. Code §  711.2 (relating to policy).

§ 711.11. Application for certificate of compliance.

 (a)  Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a certificate of compliance from the Department. Application shall be made using forms and procedures prescribed by the Department.

 (b)  The certificate shall expire 1 year from the date of issuance. Prior to the expiration of the current certificate, the Department will notify the facility of the date for the annual on-site inspection for renewal of the certificate.

 (c)  The Department will notify the appropriate SCA of applications for and issuance of a certificate of compliance to a facility or individual within the SCA’s area of responsibility.

§ 711.12. Full certificate of compliance.

 (a)  A certificate of compliance to operate the facility shall be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for the certificate of compliance under this chapter have been met.

 (b)  A certificate of compliance shall be issued to the owner of a facility and indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.

 (c)  The current certificate of compliance shall be displayed in a public and conspicuous place in the facility.

§ 711.13. Provisional certificate of compliance.

 (a)  The Department will issue a provisional certificate of compliance, valid for a specific time period of no more than 6 months, when the Department finds that a facility:

   (1)  Has substantially, but not completely, complied with applicable requirements for a certificate of compliance.

   (2)  Is complying with a course of correction approved by the Department.

   (3)  Will not adversely alter the health, welfare or safety of the facility’s clients due to existing deficiencies.

 (b)  Within 15 working days of the receipt of the deficiency report, a facility shall submit a plan to correct deficiencies noted during the site visits.

 (c)  A provisional certificate of compliance may be renewed no more than three times.

 (d)  Upon compliance with this part, a regular certificate of compliance shall be issued.

§ 711.14. Restrictions on certificate of compliance.

 (a)  A certificate of compliance shall apply only to the person, the named facility, the premises designated therein, and the activities noted, and may not be transferable.

 (b)  Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:

   (1)  Change in ownership.

   (2)  Change in name of the facility.

   (3)  Change in location of the facility.

   (4)  Change in activity.

   (5)  Change in authorized maximum capacity.

   (6)  Closing of facility.

 (c)  Failure to notify the Department under subsection (b) will result in automatic expiration of the certificate of compliance.

§ 711.15. Right to enter and inspect.

 (a)  For the purpose of determining continuing conformity of the holder of the certificate of compliance to this title, an authorized representative of the Department has a right to enter, visit and inspect a facility licensed/approved or applying for a certificate of compliance under this chapter.

 (b)  The authorized Department representative shall have full and free access to the records of the facility and its clients.

 (c)  The authorized Department representative has the right to interview clients as part of the visitation and inspection process.

Cross References

   This section cited in 28 Pa. Code §  715.3 (relating to approval of narcotic treatment programs).

§ 711.16. Notification of deficiencies.

 (a)  The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.

 (b)  The forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.

 (c)  No license may be issued until a plan of action has been approved by the Department.

§ 711.17. Refusal or revocation.

 (a)  The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:

   (1)  Failure to comply with a directive issued by the Department.

   (2)  Violation of, or noncompliance with, this chapter.

   (3)  Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.

   (4)  Gross incompetence, negligence, or misconduct in the operation of the facility.

   (5)  Fraud, deceit, misrepresentation, or bribery in obtaining or attempting to obtain a certificate of compliance.

   (6)  Lending, borrowing, or using the certificate of compliance of another facility.

   (7)  Knowingly aiding or abetting the improper granting of a certificate of compliance.

   (8)  Mistreating or abusing individuals cared for or treated by the facility.

   (9)  Continued noncompliance in disregard of this part.

   (10)  Operating a facility that by nature of its physical condition endangers the health and safety of the public.

 (b)  If the Department proposes to revoke or refuse to issue a certificate of compliance, it will give written notice to the facility by certified mail, stating the following:

   (1)  The reasons for the proposed action.

   (2)  The specific time period for the facility to correct deficiencies.

 (c)  If the facility does not correct the deficiencies within the specified time, the Department will officially notify the holder of the certificate of compliance that it must show cause why its certificate of compliance should not be revoked under 1 Pa. Code §  35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.

 (d)  Subsection (c) supplements 1 Pa. Code §  35.14.

Cross References

   This section cited in 28 Pa. Code §  715.14 (relating to denial, revocation or suspension of approval).

§ 711.18. Hearings.

 (a)  The Department will convene and conduct a show cause hearing for a facility in accordance with 1 Pa. Code §  35.37 (relating to answers to orders to show cause) and this chapter.

 (b)  An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).

 (c)  The Department may institute appropriate legal proceedings to enforce compliance with this chapter.

 (d)  This section supplements 1 Pa. Code Part II.

Cross References

   This section cited in 28 Pa. Code §  715.14 (relating to denial, revocation or suspension of approval).

Subchapter C. STANDARDS FOR INTAKE EVALUATION AND
REFERRAL ACTIVITIES


Sec.


711.41.    Project management.
711.42.    Client management.
711.43.    Client records.
711.44.    Uniform Data Collection System.
711.45.    [Reserved].

Cross References

   This subchapter cited in 28 Pa. Code §  704.1 (relating to scope).

§ 711.41. Project management.

 (a)  The intake project shall have a written procedure for the performance of the following functions:

   (1)  Orientation of the client to the drug or alcohol service delivery system, or both.

   (2)  Thorough exploration of service needs and discussion with the client concerning service options to which he may be referred.

   (3)  Development of a confidential personal history, including significant medical, social, drug or alcohol, occupational and family information.

   (4)  Prompt arrangement for delivery of the requested services.

 (b)  The intake project or treatment project shall have a written procedure for the performance of the following functions:

   (1)  Arrangement for the provision of needed medical, functional, psychological, psychiatric, social or vocational diagnostic assessments.

   (2)  Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. The plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The plan shall also include a referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.

 (c)  The intake project shall develop a written plan providing for outreach services which shall include, but not be limited to:

   (1)  Identifying persons in need of project services.

   (2)  Alerting persons and their families to the availability of project services.

   (3)  Encouraging persons to utilize the service delivery system.

 (d)  The intake project shall operate at least 5 days of the week and for a minimum of 40 hours per week. Additional hours should be appropriate to the population served by the intake project.

 (e)  The hours of operation shall be displayed conspicuously to the general public.

 (f)  A telephone number shall be displayed conspicuously to the general public.

 (g)  Procedures to be followed in psychiatric and medical emergencies shall be clearly specified in writing and made readily available to the staff.

 (h)  The intake process shall proceed expeditiously to avoid discouragement and should not exceed a period of 48 hours.

 (i)  The project shall obtain letters of agreement or understanding with primary referral sources.

§ 711.42. Client management.

 (a)  The intake project shall have written policies and procedures for communication with law enforcement authorities, local or State health or welfare authorities, as appropriate, regarding clients whose condition or its cause is reportable; for example, persons having contagious diseases or victims of suspected criminal acts such as rape or gunshot wounds, 18 Pa.C.S. §  5106 (relating to failure to report injuries by firearm or criminal act) and child abuse under the Child Protective Services Law (11 P. S. § §  2201—2224).

 (b)  The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:

   (1)  Individuals who lose consciousness.

   (2)  Minors.

   (3)  Individuals with communicable diseases.

   (4)  Individuals requiring transfer to a hospital or other treatment facility.

   (5)  Individuals requiring detoxification.

 (c)  A client shall be observed upon intake for withdrawal symptoms from substances abused. If serious symptoms of drug/alcohol abuse, or dependence, or other physical problems are observed, prompt medical attention shall be obtained. Data obtained during the observation period shall be recorded.

 (d)  The client should be transported to the selected referral agency/resource, if possible.

 (e)  A consent to treatment form should be completed and signed by the client and intake worker at intake.

§ 711.43. Client records.

 (a)  Record requirements. The project shall maintain a client record on an individual. In addition to the requirements contained in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history.

     (iii)   Personal history.

   (2)  Drug and alcohol consent forms.

   (3)  Psychosocial evaluation.

   (4)  Referral contact.

   (5)  Record of services provided.

 (b)  Additional information. If applicable, the project shall include the following items in the client record:

   (1)  Drug and alcohol treatment and rehabilitation plans.

   (2)  Follow-up information.

 (c)  Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (d)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which shall comply with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies; disclosure of client-oriented information). The procedure shall include, but not be limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency, organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of client or guardian.

     (v)   The dated signature of witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.

§ 711.44. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A drug and alcohol data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.45. [Reserved].


Source

   The provisions of this §  711.45 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210287).

Subchapter D. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIES—RESIDENTIAL TREATMENT AND REHABILITATION


Sec.


711.51.    Intake and admission.
711.52.    Treatment and rehabilitation services.
711.53.    Client records.
711.54.    Project management services.
711.55.    Uniform Data Collection System.
711.56.    Notification of termination.
711.57.    [Reserved].
711.58.    Medication control.

Cross References

   This subchapter cited in 31 Pa. Code §  89.622 (relating to nonhospital, residential treatment and rehabilitation services); and 37 Pa. Code §  451.121 (relating to Residential Inpatient Drug and Alcohol Program).

§ 711.51. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:

   (1)  Criteria for admission.

   (2)  Treatment methodology.

   (3)  Requirements for completion of treatment.

   (4)  Involuntary discharge/termination criteria.

 (b)  Intake procedures shall include documentation of:

   (1)  Disclosure to the client of criteria for admission, treatment, completion and discharge.

   (2)  Client orientation to the project which includes, but is not limited to, a familiarization with:

     (i)   Project policies.

     (ii)   Hours of operation.

     (iii)   Fee schedule.

     (iv)   Services provided.

   (3)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history, or both.

     (iii)   Personal history.

   (4)  Consent to treatment.

   (5)  Physical examination.

   (6)  Psychosocial evaluation.

   (7)  Preliminary treatment and rehabilitation plan.

§ 711.52. Treatment and rehabilitation services.

 (a)  The project shall adopt a written plan for the coordination of client treatment and rehabilitation services, which shall include, but not be limited to:

   (1)  Defined target population.

   (2)  Treatment models utilized by the project.

   (3)  Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.

 (b)  The project shall obtain written letters of agreement or understanding with primary referral sources.

 (c)  An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:

   (1)  Short and long-term goals for treatment, as formulated by both staff and client.

   (2)  Type and frequency of treatment and rehabilitation services.

   (3)  Proposed type of support service.

 (d)  Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.

 (e)  The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.

 (f)  Counseling shall be provided to a client on a regular and scheduled basis.

 (g)  The project shall assist the client in obtaining the following supportive services when necessary:

   (1)  Medical/dental.

   (2)  Psychiatric.

   (3)  Legal.

   (4)  Economic.

   (5)  Educational.

   (6)  Vocational.

   (7)  Recreational/social.

§ 711.53. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements contained in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Record of services provided.

   (3)  Referral contact.

   (4)  Progress notes.

   (5)  Individualized drug and alcohol treatment and rehabilitation plan.

   (6)  Aftercare plan, if applicable.

   (7)  Follow-up information.

   (8)  Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.

 (b)  Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which complies with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but is not limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency, organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of client or guardian.

     (v)   The dated signature of witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.

§ 711.54. Project management services.

 (a)  When food is prepared at the project site and preparation is not directly supervised by the parent health care facility, then the drug and alcohol project shall have written policies and procedures for its dietetic services which includes, but is not limited to:

   (1)  Purchasing of food and equipment.

   (2)  Receiving, storing and preserving of food stuff.

   (3)  Proper preparation of food.

   (4)  Safety and sanitation; including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work areas.

   (5)  Personal hygiene for those in food preparation areas.

   (6)  Special dietary needs.

 (b)  The project shall develop a written client aftercare policy.

 (c)  The project shall develop a written client follow-up policy.

 (d)  The project shall develop a written plan providing for outreach services which includes, but is not limited to:

   (1)  Identifying persons in need of project services.

   (2)  Alerting persons and their families to the availability of project services.

   (3)  Encouraging persons to utilize the service delivery system.

§ 711.55. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.56. Notification of termination.

 (a)  The project director shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision terminating his treatment.

§ 711.57. [Reserved].


Source

   The provisions of this §  711.57 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210291).

§ 711.58. Medication control.

 When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

Subchapter E. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIES—SHORT-TERM DETOXIFICATION


Sec.


711.61.    Intake and admission.
711.62.    Client records.
711.63.    Project management services.
711.64.    Uniform Data Collection System.
711.65.    Notification of termination.
711.66.    Medication control.
711.67.    Physical plant.

Cross References

   This subchapter cited in 31 Pa. Code §  89.621 (relating to inpatient detoxification services).

§ 711.61. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which includes, but, is not limited to:

   (1)  Criteria for admission.

   (2)  Treatment methodology.

   (3)  Requirements for completion of treatment.

   (4)  Involuntary discharge/termination criteria.

 (b)  Intake procedures other than initial medical care shall be performed at a time when the immediate physiological effects of drug and alcohol abuse have subsided.

 (c)  Intake procedures shall include documentation of:

   (1)  Disclosure to the client of criteria for admission, treatment, completion and discharge.

   (2)  Client orientation to the project which includes, but is not limited to, a familiarization with:

     (i)   Project policies.

     (ii)   Hours of operation.

     (iii)   Fee schedule.

     (iv)   Services provided.

   (3)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history, or both.

     (iii)   Personal history.

   (4)  Consent to treatment.

   (5)  Physical examination.

   (6)  Psychosocial evaluation.

§ 711.62. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Drug and alcohol support plan.

   (3)  Progress notes.

   (4)  Record of services provided.

   (5)  Aftercare plans, if applicable.

   (6)  Follow-up information.

   (7)  Verification that work done by the client at the project is an integral part of the drug and alcohol support plan.

 (b)  Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which shall comply with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency, or organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of the client or guardian.

     (v)   The dated signature of a witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.

§ 711.63. Project management services.

 (a)  When food is prepared at the project site and preparation is not directly supervised by the parent health care facility, then the drug and alcohol project shall have written policies and procedures for its dietetic services which include, but are not limited to, the following:

   (1)  Purchasing of food and equipment.

   (2)  Receiving, storing and preserving of food stuff.

   (3)  Proper preparation of food.

   (4)  Safety and sanitation, including the preparation, handling and storage of foods, the care and cleaning of dishes, utensils and work area.

   (5)  Personal hygiene for those in food preparation areas.

   (6)  Special dietary needs.

 (b)  There shall be a written plan that delineates specific service planning and counseling approaches used to promote patient interest in participating in necessary treatment, following the detoxification process.

 (c)  The project shall assist the client in obtaining the following supportive services, when necessary:

   (1)  Medical/dental.

   (2)  Psychiatric.

   (3)  Legal.

   (4)  Economic.

   (5)  Educational.

   (6)  Vocational.

   (7)  Recreational/social.

 (d)  The project shall develop a written client aftercare policy.

 (e)  The project shall develop a written client follow-up policy.

 (f)  The project shall develop a written plan providing for outreach services which shall include, but not be limited to:

   (1)  Identifying persons in need of project services.

   (2)  Alerting persons and their families to the availability of project services.

   (3)  Encouraging persons to utilize the service delivery system.

 (g)  The project staff shall obtain written letters of agreement or understanding with primary referral sources.

§ 711.64. Uniform Data Collection System.

 (a)  If a project utilized Department funds, it shall comply with the Department’s UDCS.

 (b)  A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.65. Notification of termination.

 (a)  The project director shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision to terminate treatment.

§ 711.66. Medication control.

 When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients which shall include, but not be limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

§ 711.67. [Reserved].


Source

   The provisions of this §  711.67 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210295).

Subchapter F. STANDARDS FOR INPATIENT NONHOSPITAL
ACTIVITIES—TRANSITIONAL LIVING FACILITIES (TLFs)


Sec.


711.71.    Intake and admission.
711.72.    Client records.
711.73.    Client management services.
711.74.    Uniform Data Collection System.
711.75.    Notification of termination.
711.76.    Medication control.
711.77.    Physical plant.

§ 711.71. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which shall include, but not be limited to:

   (1)  Criteria for admission.

   (2)  Guidelines for completion of residency.

   (3)  Involuntary discharge/termination criteria.

 (b)  Intake procedures shall include documentation of:

   (1)  Disclosure to the client of criteria for admission, completion and discharge.

   (2)  Client orientation to the project which shall include, but not be limited to, a familiarization with:

     (i)   House rules.

     (ii)   Hours of operation.

     (iii)   Fee schedule.

     (iv)   Services provided.

   (3)  Basic personal data.

   (4)  Agreement for residency.

§ 711.72. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Drug and alcohol referral contact.

   (3)  Activity notes.

 (b)  Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which shall comply with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency, or organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of the client or guardian.

     (v)   The dated signature of a witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.

§ 711.73. Client management services.

 (a)  The project shall adopt a written plan for the coordination of residential services which shall include, but not be limited to:

   (1)  Defined target population.

   (2)  Written procedures for the management of residential services for clients.

 (b)  The project shall obtain written letters of agreement or understanding with primary referral sources.

§ 711.74. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.75. Notification of termination.

 (a)  The project director shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision to terminate treatment.

§ 711.76. Medication control.

 When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

§ 711.77. [Reserved].


Source

   The provisions of this §  711.77 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210298).

Subchapter G. STANDARDS FOR PARTIAL HOSPITALIZATION ACTIVITIES


Sec.


711.81.    Intake and admission.
711.82.    Treatment and rehabilitation services.
711.83.    Client records.
711.84.    Project management services.
711.85.    Uniform Data Collection System.
711.86.    Notification of termination.
711.87.    Medication control.
711.88.    [Reserved].

§ 711.81. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which shall include, but not be limited to:

   (1)  Criteria for admission.

   (2)  Treatment methodology.

   (3)  Requirements for completion of treatment.

   (4)  Involuntary discharge/termination criteria.

 (b)  Intake procedures shall include documentation of:

   (1)  Disclosure to the client of criteria for admission, treatment, completion and discharge.

   (2)  Client orientation to the project which shall include, but is not limited to, a familiarization with:

     (i)   Project policies.

     (ii)   Hours of operation.

     (iii)   Fee schedule.

     (iv)   Services provided.

   (3)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history, or both.

     (iii)   Personal history.

   (4)  Consent to treatment.

   (5)  Physical examination, if applicable.

   (6)  Psychosocial evaluation.

   (7)  Preliminary treatment and rehabilitation plan.

§ 711.82. Treatment and rehabilitation services.

 (a)  The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:

   (1)  Defined target population.

   (2)  Treatment models utilized by the project.

   (3)  Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.

 (b)  The project shall obtain written letters of agreement or understanding with primary referral sources.

 (c)  An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:

   (1)  Short and long-term goals for treatment, as formulated by both staff and client.

   (2)  Type and frequency of treatment and rehabilitation services.

   (3)  Proposed type of support service.

 (d)  Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.

 (e)  The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.

 (f)  Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:

   (1)  Individual counseling, at least twice weekly.

   (2)  Group counseling, at least twice weekly.

   (3)  Family counseling, as appropriate.

   (4)  Couple counseling, as appropriate.

 (g)  The project shall assist the client in obtaining the following supportive services when necessary:

   (1)  Medical/dental.

   (2)  Psychiatric.

   (3)  Legal.

   (4)  Economic.

   (5)  Educational.

   (6)  Vocational.

   (7)  Recreational/social.

§ 711.83. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Referral contact.

   (3)  Individualized drug and alcohol treatment and rehabilitation plan.

   (4)  Progress notes.

   (5)  Aftercare plans, if applicable.

   (6)  Record of services provided.

   (7)  Follow-up information.

   (8)  Verification that work done by the client at the project is an integral part of this treatment and rehabilitation plan.

 (b)  Client access to records. A client has the right to inspect his own records. The Project Director may temporarily remove portions of the record, prior to the inspection by the client, if that director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which complies with 4 Pa.Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency or organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of the client or guardian.

     (v)   The dated signature of a witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.

§ 711.84. Project management services.

 (a)  The partial hospitalization project shall operate at least 5 days of the week and for a minimum of 40 hours per week. Additional hours should be appropriate to the population served by the partial hospitalization project.

 (b)  The hours of project operation shall be displayed conspicuously to the general public.

 (c)  A telephone number shall be displayed conspicuously to the general public for emergency purposes.

 (d)  The project shall develop a written aftercare policy.

 (e)  The project shall develop a written follow-up policy.

 (f)  The project shall develop a written plan providing for outreach services which shall include, but not be limited to:

   (1)  Identifying persons in need of project services.

   (2)  Alerting persons and their families to the availability of project services.

   (3)  Encouraging persons to utilize the service delivery system.

§ 711.85. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A data collection shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.86. Notification of termination.

 (a)  The project director shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision to terminate treatment.

§ 711.87. Medication control.

 When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients which includes, but is not limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

§ 711.88. [Reserved].


Source

   The provisions of this §  711.88 reserved March 1, 2002, effective March 2, 2002, 32 Pa.B. 1183. Immediately preceding text appears at serial page (210302).

Subchapter H. STANDARDS FOR OUTPATIENT ACTIVITIES


Sec.


711.91.    Intake and admission.
711.92.    Treatment and rehabilitation services.
711.93.    Client records.
711.94.    Project management services.
711.95.    Uniform Data Collection System.
711.96.    Notification of termination.
711.97.    Medication control.
711.98.    Physical plant.

Cross References

   This subchapter cited in 31 Pa. Code §  89.623 (relating to outpatient services); and 37 Pa. Code §  451.111 (relating to Alcohol or Drug Outpatient Treatment Program).

§ 711.91. Intake and admission.

 (a)  The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:

   (1)  Criteria for admission.

   (2)  Treatment methodology.

   (3)  Requirements for completion of treatment.

   (4)  Involuntary discharge/termination criteria.

 (b)  Intake procedures shall include documentation of:

   (1)  Disclosure to the client of criteria for admission, treatment, completion and discharge.

   (2)  Client orientation to the project which includes, but is not limited to, a familiarization with the following:

     (i)   Project policies.

     (ii)   Hours of operation.

     (iii)   Fee schedule.

     (iv)   Services provided.

   (3)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history, or both.

     (iii)   Personal history.

   (4)  Consent to treatment.

   (5)  Physical examination, if applicable.

   (6)  Psychosocial evaluation.

   (7)  Preliminary treatment and rehabilitation plan.

§ 711.92. Treatment and rehabilitation services.

 (a)  The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:

   (1)  Defined target population.

   (2)  Treatment models utilized by the project.

   (3)  Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.

 (b)  The project shall obtain written letters of agreement or understanding with primary referral sources.

 (c)  An individual treatment and rehabilitation plan shall be developed with a client. The plan shall include, but not be limited to, written documentation of:

   (1)  Short- and long-term goals for treatment, as formulated by both staff and client.

   (2)  Type and frequency of treatment and rehabilitation services.

   (3)  Proposed type of support service.

 (d)  Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.

 (e)  The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.

 (f)  Counseling shall be provided to a client on a regular and scheduled basis.

§ 711.93. Client records.

 (a)  Record requirements. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. In addition to the requirements in §  115.32 (relating to contents), the client record shall include the following:

   (1)  Drug and alcohol consent forms.

   (2)  Record of services provided.

   (3)  Referral contact.

   (4)  Progress notes.

   (5)  Individualized drug and alcohol treatment and rehabilitation plan.

   (6)  Aftercare plans, if applicable.

   (7)  Follow-up information.

 (b)  Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

 (c)  Confidentiality.

   (1)  A written procedure shall be developed by the project director which complies with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:

     (i)   Confidentiality of client identity and records.

     (ii)   Staff access to client records.

   (2)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

     (i)   The name of the person, agency, or organization to whom disclosure is made.

     (ii)   The specific information disclosed.

     (iii)   The purpose of disclosure.

     (iv)   The dated signature of the client or guardian.

     (v)   The dated signature of a witness.

     (vi)   The expiration date of the consent.

   (3)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

   (4)  Where consent is not required, the project personnel shall:

     (i)   Fully document the disclosure in the client records.

     (ii)   Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.

§ 711.94. Project management services.

 (a)  Outpatient projects shall make an effort to adjust the hours of project operations to meet client needs, taking into account other client time commitments such as employment and school schedules.

 (b)  The hours of project operation shall be displayed conspicuously to the general public.

 (c)  A telephone number shall be displayed conspicuously to the general public for emergency purposes.

 (d)  The project shall develop a written client aftercare policy.

 (e)  The project shall develop a written client follow-up policy.

 (f)  The project shall develop a written plan providing for outreach services which include, but not be limited to:

   (1)  Identifying persons in need of project services.

   (2)  Alerting persons and their families to the availability of project services.

   (3)  Encouraging persons to utilize the service delivery system.

 (g)  Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).

§ 711.95. Uniform Data Collection System.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (b)  A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project’s performance.

§ 711.96. Notification of termination.

 (a)  The project director shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have the opportunity to request reconsideration of a decision terminating treatment.

§ 711.97. Medication control.

 When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding all medications used by clients which includes, but is not limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

§ 711.98. Physical plant.

 When the project is not physically located within a health care facility, it shall be site visited annually for the following requirements:

   (1)  Counseling areas.

   (2)  Office space.

   (3)  Lavatories.

   (4)  Fire escape/emergency exits.

   (5)  Fire extinguishers.

   (6)  General maintenance.

   (7)  Certificate of Occupancy from the Department of Labor and Industry or its equivalent.

   (8)  Compliance with applicable local ordinances and regulations.

Subchapter I. [Reserved]


empty

§ § 711.101—711.106. [Reserved].


Source

   The provisions of these § §  711.101—711.106 reserved December 5, 1997, effective December 6, 1997, 27 Pa.B. 6330. Immediately preceding text appears at serial pages (210306) to (210309).



No part of the information on this site may be reproduced for profit or sold for profit.

This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.