14-118 C.M.R. ch. 2, § F - TREATMENT

1. All treatment services provided for DEEP referrals required under these regulations shall be provided by a clinician licensed and qualified under criteria set forth under B.3. or certified as a Certified Alcohol and Drug Counselor (CADC) pursuant to Maine Revised Statutes, Title 32, Chapter 81. Treatment for DEEP referrals shall not be provided by an Alcohol and Drug Counseling Aide (ADCA).

2. The Private Provider shall have policies to ensure that the clinical substance abuse evaluation and treatment of a DEEP referred client shall be consistent with that of any other referred client.

3. The Private Provider shall have procedures to ensure that:

a. He/she is familiar with DEEP reporting requirements; and

b. Reporting requirements will be fulfilled.

4. Every Private Provider shall have clinical supervision provided by individuals who are licensed and qualified in compliance with Section B.3. Community-based Service Provider-Private Providers receiving and providing clinical supervision shall be in compliance with the statutes and rules of their individual licensing board(s).

a. Supervision may be conducted on an individual or group basis or a combination of both. DEEP Private Providers may receive peer supervision provided that there are three (3) or more clinicians involved, one of who shall be a Licensed Alcohol Drug Counselor (LADC) or holds a substance abuse specialty credential.

b. Clinical supervision shall:

(1) Occur at a minimum frequency of one (1) hour of clinical supervision for each twenty (20) hours of direct client contact by the clinician or not less than one (1) hour per calendar quarter in the case of a part time clinician.

(2) Be documented, and the documentation shall be part of the clinical supervision file.

(3) Supervision shall include the following duties:

(a) Review of case records;

(b) Participate in the development of the Private Provider's training plan and upgrading of clinical skills;

(c) Maintain a log of clinical supervision meetings that shall contain date, duration, and content of supervision meetings.

(d) Clinical supervisors shall document any discussion or changes pertaining to the client's treatment plan.

c. Private Providers shall have a signed clinical supervision agreement for individual or peer supervision. The agreement shall describe the services provided, state that all supervision activities will be documented in compliance with these regulations, and state that supervision will be provided in compliance with Federal Confidentiality Regulations.

5. Each Private Provider offering DEEP treatment services shall have written admission policies and procedures, which shall include:

a. Procedures to make clients aware of the Private Provider's philosophies, rules and regulations; and

b. A fee schedule and payment policies that shall be fully explained to the client upon admission into treatment.

6. No DEEP Private Provider conducting evaluation or treatment services for DEEP referrals shall discriminate against any person in any manner prohibited by the laws of Maine or the United States.

7. Each client shall receive a complete assessment, including clinical consideration of the client's needs, and a written individual treatment plan based on this assessment. The assessment shall include, but not be limited to:

a. Pertinent medical information.

b. A history of the use of alcohol and other drugs, including the age of onset, duration, patterns, and consequences of use, types of and responses to previous treatment, and use of alcohol and other drugs by family members.

c. An emotional and behavioral assessment of the client.

d. A social assessment of each client, which shall include information on childhood, environment and home, religion, education, financial status, peer group, family circumstances, employment, and military service.

e. Consideration of all information from the referral sources.

f. Physical, emotional, behavioral, social, recreational, and, when appropriate, legal, vocational, transportation, and educational needs.

g. Clinical considerations, which include a determination of the type and extent of any special examinations, tests, or evaluations, necessary for a complete assessment.

h. A list of the client's strengths and weaknesses.

i. In addition to the above, a clinical assessment for adolescents shall include, but not be limited to an assessment of:

(1) developmentally age-appropriate behaviors.

(2) cognitive functioning, of physical maturation, and of learning disabilities or attention deficits that may impact treatment.

(3) peer group functioning, including, but not limited to, education and social maturity level.

j. The clinical assessment shall conclude with a summary that contains, but is not limited to the clinician's findings, a list of the problems to be addressed during treatment, the phase of chemical dependency experienced by the client in accordance with the Completion of Treatment Guidelines, and the recommended frequency and duration of treatment.

8. The Private Provider shall have written procedures for determining whether additional evaluation is appropriate which includes a plan to assure the provision of these services, if not provided by the Private Provider.

9. The Private Provider shall have written procedures for determining whether a medical examination is necessary and a procedure for referring the client, if deemed appropriate.

10. An individually written treatment plan consistent with treatment philosophy shall be maintained for each client. The plan shall be:

a. based on the clinical assessment required by Section F.7.

b. developed within three (3) sessions

c. based on the Completion of Treatment Guidelines adopted by the Office.

11. Individual treatment plans shall contain the following elements:

a. Problems to be addressed during treatment;

b. Measurable long-term treatment goals that relate to problems identified in the assessment;

c. Measurable short-term goals leading to the completion of the long-term goals;

(1) Time frames for the anticipated dates of achievement/completion of each goal, or for reviewing progress towards goals.

(2) Specification and description of the indicators used to assess the individual's progress.

(3) The treatment procedures proposed to assist the client in achieving these goals, including:

(a) Type and frequency of services and/or assigned activities to be provided

(b) Referrals for needed services that are not provided directly by the Private Provider.

d. Documentation of participation by the client in the treatment planning process or the reason why the client did not participate.

12. The treatment plan shall be reviewed and updated during the course of treatment.

a. This review shall:

(1) Document the degree to which the client is meeting his/her treatment goals;

(2) Modify existing goals or establish new ones as necessary.

b. The updated plan shall be signed by the counselor and client, as appropriate, at the time of review.

c. The plan shall be reviewed each time an issue is identified that impacts the current treatment plan or every 3 months.

13. Progress notes, serving as the basis for evaluating treatment and updating treatment plans, shall be maintained on each client. Progress notes shall:

a. document implementation of the treatment plan;

b. document all treatment rendered to the client;

c. contain descriptions of changes in the client's condition, his/her response to treatment, and the response of significant others to his/her treatment.

14. An aftercare plan shall be developed. The aftercare plan shall:

a. be developed with the participation of the client and, where indicated, family guardian, or significant other.

b. be in accordance with the client's reassessed needs at the time of transfer.

c. describe, when appropriate, the Private Provider's responsibility for facilitating the transfer of the client to further services, or the client's support system.

15. DEEP clients participating in a Program within a protective environment, as determined by the Director, will be required to complete a minimum of one (1) contact hour per week over a period of not less than thirty (30) days after discharge from the protective environment prior to submission of the completion form or other documentation used for consideration of treatment completion.

16. DEEP clients receiving treatment while residing in a "halfway house" or "pre-release center" may complete DEEP requirements provided that the client registers for the Completion of Treatment Program and receives DEEP treatment services from an approved DEEP provider located outside of the halfway house or pre-release center who is employed by an entity other than the halfway house or pre-release center. DEEP clients who do not complete the DEEP process while in the halfway house, pre-release center, or Residential Rehabilitation Program shall complete a minimum of one (1) contact hour per week over a period of not less than thirty (30) days after discharge from the Program.

17. A discharge summary shall be completed. The discharge summary shall:

a. describe the client's course of treatment.

b. make reference to the client's progress toward planned goals as listed in the treatment plan.

c. describe the client's condition at discharge.

18. A case record shall be maintained for each client.

a. The client case record describes the client's health status at the time of admission, the services provided, the client's progress during treatment, and the client's health status at the time of discharge.

b. The case record shall include, but not be limited to:

(1) Identification data;

(2) Reports from referring sources;

(3) Result of the client's clinical substance abuse evaluation;

(4) Results of the client's clinical assessment;

(5) A statement signed by the client declaring his/her knowledge of the fee schedule;

(6) Treatment plans and treatment plan updates;

(7) Progress notes;

(8) The aftercare plan;

(9) The discharge summary;

(10) Whenever appropriate to the client's treatment, the case record shall additionally include, but not be limited to:

(a) Family evaluation;

(b) Correspondence pertinent to the case;

(c) Signed releases of information;

(d) Referral for service to other agencies, including reasons for referral; and

(e) Discharge summary from any prior treatment for substance abuse.

19. Every Private Provider shall have written discharge policies and procedures that shall include:

a. Procedures for planning the client's discharge in consultation with the client when one of the following conditions are met:

(1) It is evident to the Community-based Service Provider that the client has received optimum benefit from treatment and further progress requires either the return to the community or the client's referral to another type of treatment Program; or

(2) the established length of treatment is about to expire for the client.

b. A statement describing indicators to be used in determining successful Program completion.

20. The Community-based Service Provider will communicate the results of treatment to DEEP within fifteen (15) working days on forms provided by DEEP.

a. The treatment results 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 treatment or a representative of the agency. Treatment 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 treatment result is not being reported as a result of non-payment of fees, the provider shall notify the DEEP program to that effect within fifteen (15) days.

21. Community-based Service Providers shall submit documentation on forms provided by the DEEP that treatment is complete. The Director will decide and be responsible for determining that treatment is complete.

a. The DEEP staff, at their discretion, may request additional documentation.

b. The Director will forward forms to the Secretary of State, Bureau of Motor Vehicle, Division of Driver Licensing Services when it is determined that treatment is complete.

c. The Director may return forms to the community based service provider who provided the treatment within five (5) working days when it is determined that treatment is not complete. The Director will provide a written explanation of the determination if it is determined that treatment is not complete.

22. Registration forms for clients who discontinue the treatment process without notification for a ninety (90) day period shall be returned to DEEP. Clients will be required to contact DEEP for re-referral.

a. Clients returning to the same community-based service provider shall receive a client status and treatment plan review prior to continuation of treatment.

b. Clients who choose a different Community-based Service Provider shall receive a client status and treatment plan review. The chosen provider shall request a copy of the clinical assessment summary, treatment plan, and discharge summary from the previous provider. The documentation shall be reviewed with the client prior to continuation of treatment.

c. The Community-based Service Provider shall notify DEEP when the registration form is being held for nonpayment of services.

23. Clients who have completed treatment six (6) months prior to submitting documentation of treatment completion shall be required to provide documentation of compliance with Section A, Satisfactory Completion of Treatment, through referral to an approved community-based Program or Private Provider for a status update evaluation.

24. Participation in a self-help group(s), in and of itself, will not be accepted in lieu of, or as a substitute for, treatment by an approved Community-based Service Provider or out-of-state or military treatment provider.

25. Community-based Service Providers shall justify for DEEP any extension of treatment that may go beyond the recommended number of clinical hours and/or time frames established by the Completion of Treatment Guidelines.

a. At such time the Community-based Service Provider decides the client requires treatment beyond existing guidelines, the counselor shall submit a written request to provide the additional services. The Community-based Service Provider shall not provide the additional services until the request receives approval.

b. The request shall contain:

(1) a statement identifying the phase of substance abuse/dependence, modality of treatment and the number of clinical hours/days completed and recommended; and

(2) a summary of the reason(s) why the treatment must extend beyond the existing guidelines; and

(3) a list of the issues/problems that will be resolved as a result of the extension;

(4) the projected number of sessions/days necessary for completion; and

(5) the client's signature documenting awareness of the request.

a. The client case record shall contain copies of the materials used to justify the extension.

b. DEEP shall grant or refuse the extension request. Additional services shall not be provided prior to request approval.

c. Any client who disagrees with DEEP's approval of the need to extend the number of treatment clinical hours/days may request a second opinion as described in Section H.

26. Community-based Service Providers shall justify for DEEP, on forms provided by DEEP, treatment that is less than the thresholds established by the Completion of Treatment Guidelines. The form shall be submitted with other required documentation at the time of completion. The client case record shall contain copies of the materials used to justify the early completion. DEEP shall grant or refuse the justification for early completion.

Any client who disagrees with DEEP's refusal of the justification for early completion may request a second opinion as described in Section H.

27. Private Providers shall be in compliance with Federal Confidentiality Regulations as outlined in 42 Code of Federal Regulations, Part 2.

a. Case records shall be protected in accordance with Federal Confidentiality Regulations.

b. There shall be a written plan describing methods and procedures used to ensure confidentiality of case records, including electronic client data, if appropriate.

c. T of client records in case of program closure, including electronic client data, if appropriate. The plan for disposition of client records in case of program closure shall be in compliance with federal confidentiality and DEEP regulations.

d. Case records shall be preserved for a minimum of six (6) years except in the case of a minor, where they shall be kept for six (6) years following the client's 18th birthday.

e. All clients shall be informed and made aware of client rights regarding confidentiality. The following statement on confidentiality shall be read to all clients at the time of application or as soon as possible thereafter. This statement shall be signed or initialed by the client. A copy of the statement shall be given to the client and a copy shall be included in the case record.

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:

(1) The patient consents in writing;

(2) The disclosure is allowed by a court order; or

(3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violations of Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information relating to a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

I understand that I have a legal right to report any violation to the Office of Substance Abuse in Augusta.

28. The DEEP Private Provider shall arrange for a person of authority to have access to DEEP case records in the case of the DEEP provider's absence or incapacity. The Private Provider shall have a signed agreement stating the responsibility of a person of authority that shall include:

a. providing the DEEP Director or his/her duly appointed representative with the documentation and/or those DEEP client case records requested during the DEEP provider's absence or incapacity;

b. the authority to maintain the case records for the required time period in compliance with federal confidentiality and DEEP regulations prior to disposing of the records in the event that the Private Provider is diagnosed as permanently incapacitated or the Private Provider's death; and

c. understanding and adherence to Federal Confidentiality Regulations.

Notes

14-118 C.M.R. ch. 2, § F