14-118 C.M.R. ch. 2, § E - THE CLINICAL SUBSTANCE ABUSE EVALUATION, SECOND OPINION AND STATUS UPDATE EVALUATION

1. All clinical substance abuse evaluations, second opinions, and status updates provided by approved Community-based Service Providers shall be conducted as follows:

a. All clinical substance abuse evaluations, second opinions, and status update evaluations shall be provided by a clinician licensed and qualified under criteria set forth under Section B.3.or certified as a Certified Alcohol and Drug Counselor (CADC) pursuant to the Maine Revised Statutes Title 32, Chapter 81. Clinical substance abuse evaluations, second opinions and status updates shall not be provided by an Alcohol and Drug Counseling Aide (ADCA).

Clinical substance abuse evaluations, second opinions and status update evaluations shall consist of a minimum of two (2) and a maximum of four (4) clinical hour sessions, with a minimum of five working days between the first and second session, provided that if, after the first session, the evaluator and the client both agree upon a positive finding, the evaluator may waive any subsequent sessions. When the client agrees to a positive finding during the first evaluation session, the client may request to enter directly into treatment. Waiving the evaluation will be communicated to DEEP by the Community-based Service Provider within five (5) working days on a form provided by DEEP. A copy of the DEEP form shall be maintained in the client file.

b. No group evaluations will be performed.

c. The Community-based Service Provider conducting the clinical substance abuse evaluation, second opinion, or status update evaluation shall require the presence of a significant other or concerned person at one of the evaluation sessions, provided that if the first session results in a positive finding, the evaluator may waive the need for a significant other or concerned person. If, after being requested to do so, a client refuses to bring a significant other or concerned person to an evaluation session, the refusal shall, by itself, result in an unsatisfactory completion of the evaluation. When, in the judgment of the evaluator, exceptional circumstances prevent the client from bringing a significant other or concerned person to the evaluation, these reasons shall be documented in the client's case file and this failure shall not, by itself, result in an unsatisfactory completion of the evaluation.

d. Clinical substance abuse evaluations, second opinions, and status update evaluations shall be documented. The documentation shall include, but not be limited to, the following:

(1) A mental status assessment.

(2) A psychosocial history, including family background, employment, education, legal and medical history.

(3) A detailed history of alcohol and other drug use, including age of first use, evidence of tolerance or withdrawal, memory loss, consumption, list of all drugs used (past and present, patterns of use and family history of alcohol/drug problems).

(4) The history of previous treatment for a substance abuse disorder, if any, including past participation in self-help, and any significant period of abstinence or recovery.

(5) Diagnostic assessment test instrument scores and their clinical interpretation.

(6) The content of the interview with at least one significant other.

(7) A description of the client's current alcohol and/or other drug use status.

(8) A clinical summary, including the DSM IV diagnosis and the stage of chemical abuse/dependency in accordance with the Completion of Treatment Guidelines, any recommendations for further service, and the client's current risk for repeating an alcohol or other-drug related offense.

e. Status update evaluations shall include documentation of previous treatment,including a copy of the discharge summary and aftercare plan.

f. The Community-based Service Provider shall require abstinence from alcohol and/or other non-prescribed drugs during the course of the evaluation.

2. Upon completion of the last scheduled session, the client will be informed of the results of the evaluation. The result shall be a) an incomplete evaluation, b) a negative finding, c) a positive finding, or d) a positive finding-in remission.

a. Incomplete Evaluation. If the client fails to attend all the required evaluation sessions, fails to bring a significant other, fails to complete the evaluation or fails to comply with any other reasonable requirement that is a customary part of the evaluation, the client will be informed that he or she has not satisfactorily completed the evaluation.

Any time an evaluation is not completed within six (6) months, the client will be required to undergo another complete evaluation. However, if the first evaluation has resulted in a positive finding, any subsequent evaluation will be conducted as a second opinion evaluation.

b. Negative Finding. When the evaluation determines that there is no clinical evidence that a client has an alcohol or other drug problem requiring treatment, the client will be informed that the evaluation, in the opinion of the Community-based Service Provider, has resulted in a negative finding.

c. Positive Finding. When the evaluation determines that a client has an alcohol or other drug problem requiring treatment, the client will be informed that, in the opinion of the Community-based Service Provider, the evaluation has resulted in a positive finding that will require either outpatient, non residential or residential treatment. The consequences of a client's failure to comply with the treatment requirements will be explained to the client.

d. Positive Finding - in Remission. When the evaluation determines that the client has had an alcohol or other drug problem for which the client has demonstrated clinical evidence of remission sufficient to comply with the Satisfactory Completion of Treatment as defined in Section A, the client will be informed that, in the opinion of the Community-based Service Provider, the evaluation has resulted in a positive-in remission finding.

3. When an evaluation results in a positive finding, the Community-based Service Provider will prescribe a type of treatment that is, in the evaluator's judgment, appropriate and likely to be beneficial. The Community-based Service Provider will give the client the names and addresses of at least three (3) different Private Providers and/or Programs that are licensed or approved to provide the type of treatment services prescribed. The client may then choose an approved Community-based Service Provider of the prescribed treatment services.

4. The Community-based Service Provider will communicate the evaluation result to DEEP within ten (10) working days on forms provided by DEEP.

a. The evaluation result may be hand-delivered to the DEEP office provided that the documentation is in a sealed envelope and delivered by the clinician who provided the evaluation or a representative of the agency. Evaluation results delivered to the DEEP office by either the client or any other individual representing the client will not be accepted.

b. The clinician shall notify DEEP when the evaluation result is not being reported as a result of non-payment of fees, the provider shall notify the DEEP program to that effect within ten (10) days.

5. The Director will review the forms and other submitted documentation and will decide and be responsible for determining the evaluation result. The Director, at his/her discretion, may request additional documentation that has resulted in the recommendation.

a. The Director will notify, verbally, when possible, and in writing, the Community-based Service Provider and the client, when the Director disagrees with the evaluation result.

b. When treatment is not required as a result of the Director's decision, DEEP will forward forms to the Secretary of State, Bureau of Motor Vehicle, Division of Driver Licensing Services.

6. Anytime the client disagrees with a positive finding resulting from the first evaluation, he/she may request a second opinion evaluation.

7. In prescribing a treatment regimen consisting of residential treatment, the evaluator shall consider but not be limited to the following factors:

a. Prior and ongoing treatment in a non-residential or outpatient setting;

b. Physical addiction to alcohol and/or other drugs;

c. Prior residential care;

d. Ongoing involvement with the criminal justice system due to substance abuse;

e. Ongoing involvement with the social service system due to substance abuse; and

f. Prior OUI offenses.

8. In prescribing a treatment regimen consisting of non-Residential Rehabilitation, the evaluator shall consider, in addition to all of the factors listed above, the following factors:

a. Extent of family, or significant other, support system

b. Availability of a substance free home and work environment conducive to Intensive Outpatient treatment, and

c. Ability to commute on a daily basis to and from non-Residential Rehabilitation site.

9. When prescribing a treatment regimen, outpatient, non-Residential Rehabilitation, or Residential Rehabilitation, the evaluator will document the reasons and maintain the documentation within the client's record.

Notes

14-118 C.M.R. ch. 2, § E