Ga. Comp. R. & Regs. R. 111-8-53-.12 - Patient Screening, Assessment, and Admission

(1) A program may only admit and retain patients whose known needs can be met by the program in accordance with its program purpose and description and applicable federal and state laws and regulations. Written policies and procedures for patient referral, intake, screening, assessment, and admission must be established and implemented and must include the following provisions or requirements.

(a) Screening. All applicants for admission must be initially screened by program staff to determine eligibility for admission. No applicant may be admitted until it has been verified that he or she meets all applicable criteria and that the sources and methods of verification have been recorded in the applicant's case folder. The screening process must include:

1. Verification, to the extent possible, of an applicant's identity, including name, address, date of birth, and other identifying data;

2. Drug history and current status, including determination and substantiation, to the extent possible, of the duration of substance dependence;

3. If an applicant has been previously discharged from treatment at another narcotic treatment program, the admitting program must initiate an investigation into the applicant's prior treatment history, inquiring of the last program attended the reasons for discharge from treatment;

4. If an applicant is 18 years of age or older, verification of dependence on opium, morphine, heroin or any derivative or synthetic drug of that group for a period of one year; and

5. If an applicant is under 18 years of age, verification that the applicant has had two documented unsuccessful attempts at short-term detoxification or drug-free treatment within a 12 month period to be eligible for maintenance treatment. No person under 18 years of age may be admitted to maintenance treatment unless a parent, legal guardian, or responsible party consents in writing to such treatment.

(b) Assessment. Each patient admitted to the program must be assessed by the medical director, the program physician, or an appropriately licensed and qualified member of the medical staff who has been determined to be qualified by law, education, training, and experience to perform or coordinate the provision of such assessments. A program shall not admit a patient for a maintenance program unless it is the most appropriate treatment modality. Before any medication is prescribed or administered, a patient who is admitted to a program shall be assessed by the medical director, the program physician, or an appropriately licensed and qualified member of the medical staff who has been determined to be qualified by law, education, training, and experience to perform or coordinate the provision of such assessments. The assessment must include:

1. Medical history, including HIV status, pregnancy, current medications (prescription and non-prescription), and active medical complications;

2. Psychiatric history and current medical status examination;

3. Determination if the applicant needs special services, such as treatment for alcoholism, or psychiatric services, and determination that the program is capable of addressing these needs either directly or through referral;

4. Explanation of treatment options, detoxification rights, and program charges, including fee agreement, signed by the applicant; and

5. An in-person physical examination in accordance with current and accepted standards of medical practice, complete with laboratory tests, including drug screens, HIV status (if the applicant consents to be tested), CBC and chemistry profile, and pregnancy, STD, and Mantoux TB tests, to determine dependence on opium, morphine, heroin, or any derivative or synthetic drug of that group and to determine current DSM diagnosis. The purpose of such assessments shall be to determine whether narcotic substitution, short-term detoxification, long-term detoxification, or drug-free treatment will be the most appropriate treatment modality for the patient and to establish additional educational, vocational, and treatment needs of the patient. In lieu of a complete physical examination being performed by the program physician, the individual may present a complete physical examination, dated within 90 days of admission, performed by a physician licensed in good standing in the State of Georgia. Such examination shall be updated as necessary to reflect the individual's current condition at the time of admission, including updated laboratory tests.

(c) Admission.

1. Consent. Except as otherwise authorized by law, no person may be admitted for treatment without written authorization from the patient and parent, guardian, or responsible party, if applicable. The following information must be explained by a trained staff person to the patient and other consenters, signed by the patient and such other consenters, and documented in the patient file:

(i) The program's services and treatment;

(ii) The specific condition that will be treated;

(iii) The expected charges for service including any charges that might be billed separately to the patient or other parties; and

(iv) The program's rules regarding patient conduct and responsibilities.

2. Admission Clearance. No person may receive medications unless the program first conducts an inquiry with the Central Registry in accordance with Rule 111-8-53-.19 and receives clearance from the Central Registry that the person is not simultaneously enrolled in another program.

3. Orientation. The program shall provide orientation to patients who are admitted for treatment within 24 hours of admission. Orientation must be done by a staff person who has been determined to be qualified by education, training, and experience to perform the task. Patients must be reoriented as needed to ensure an understanding of the program. Programs shall ensure that each patient signs a statement confirming that the following has been explained to the patient:

(i) The expected benefits of the treatment that the patient is expected to receive;

(ii) The patient's responsibilities for adhering to the treatment regimen and the consequences of non-adherence;

(iii) An explanation of individual treatment planning;

(iv) The identification of the staff person who is expected to provide treatment or coordinate the treatment;

(v) Program rules including requirements for conduct and the consequences of infractions, including involuntary discharge;

(vi) Patient's rights and responsibilities;

(vii) Procedures for complaining to the program and to the Department of Community Health;

(viii) Drug screening policies and procedures;

(ix) HIV education; and

(x) Community awareness.

4. Programs shall ensure that patients receive a written copy of the orientation information.

(2) Any program licensed or funded by the Department shall implement a priority admissions policy for the treatment of drug dependent pregnant females which provides for immediate access to services for any such female applying for admission, which access shall be contingent only upon the availability of space. The program must coordinate the treatment of the pregnant female with appropriate health care providers monitoring the progress of the pregnancy. Pregnancy tests for females must be conducted at admission, unless otherwise indicated.

(3) No program may provide a bounty, free services, medication, or other reward for referral of potential patients to the program.

(4) No program may provide temporary discounted financial incentives to a potential patient that does not conform to the schedule of fees established by such program as required by these rules. No program shall provide discounted fees for services during the first ninety (90) days of treatment. This paragraph (4) shall not apply to drug dependent pregnant females.

(5) Non-Admissions. The program shall maintain written logs that identify persons who were considered for admission or initially screened for admission but were not admitted. Such logs must identify the reasons why the persons were not admitted and what referrals were made for them by the program.

Notes

Ga. Comp. R. & Regs. R. 111-8-53-.12

O.C.G.A. §§ 26-5-2et seq., 31-2-5, 31-2-7.

Original Rule entitled "Patient Screening, Assessment, and Admission" adopted. F. Sep. 9, 2013; eff. Sept. 29, 2013. Amended: F. Feb. 15, 2018; eff. Mar. 7, 2018.