Tenn. Comp. R. & Regs. 0940-05-42-.07 - SERVICE RECIPIENT RECORD REQUIREMENTS

(1) Facilities shall organize and coordinate service recipient records in a manner which demonstrates that all pertinent service recipient information is accessible to all appropriate staff and to the SOTA and TDMHSAS. The service recipient Central Registry I.D. Number shall be shown on each page of the service recipient's record.

(a) Records shall be preserved for not less than 10 years even if the Facility discontinues operations. The records may be generated, maintained, or transferred in whole or in part to any recording medium that assures accurate preservation of the record.

(b) The Facility shall discuss final storage or disposition of the Facility's records with TDMHSAS 90 days in advance of the closing of a Facility.

(2) The Facility shall document that the following assessments are completed prior to the development of the Individualized Program Plan (IPP).

(a) Screening. The sources and methods of verification shall have been recorded in the prospective service recipient's case folder. The screening process shall include:

1. Verification, to the extent possible, of a prospective service recipient'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, determination by medical examination performed by a program physician of dependence on opium, morphine, heroin or any derivative or synthetic drug of that group, and determination of current Diagnostic and Statistical Manual (DSM) diagnosis.

3. Medical history, including past and family medical history, HIV status, pregnancy, a six-month history of prescriber medications, over-the-counter medications used frequently, and the patterns of specific usage of alcohol or other drugs for the past 30 days, and active medical problems.

4. Verification of other prescribed controlled medications through the PMP.

5. Psychiatric history and current mental status exam.

6. Within 14 days of admission, physical assessment and laboratory tests, including drug screens, HIV status, if the prospective service recipient consents to be tested, pregnancy, sexually transmitted diseases, Mantoux tuberculosis tests, Hepatitis C, and others as directed by the SOTA.

7. Pregnancy tests for females at admission and at least annually thereafter, unless otherwise indicated.

8. Determination if the prospective service recipient needs special services, such as treatment for alcoholism or psychiatric services, and determination that the Facility is capable of addressing these needs either directly or through referral.

9. If a prospective service recipient 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 two years or verification of one year of opioid dependence and one documented unsuccessful attempt at clinical treatment. If clinically appropriate, the program physician may waive these dependency and detoxification requirements for service recipients released from penal institutions (within six months after release) , for pregnant service recipients with a verified pregnancy and for previously treated service recipients.

10. If a prospective service recipient is under 18 years of age, verification of two documented unsuccessful attempts at detoxification within a twelve month period. Additionally, no person under 18 years of age may be admitted to maintenance treatment unless a parent, legal guardian or responsible adult designated by the SOTA consents in writing to such treatment.

(3) A voluntary, written, program-specific informed consent to treatment from each service recipient at admission to include:

(a) Information about all treatment procedures, services and other policies and regulations throughout the course of treatment, including clinic charges in the form of a fee agreement signed by the service recipient;

(b) Consent to the individualized, prescribed therapy before dosing begins, including information about potential interactions with and adverse reactions to other substances, including those reactions that might result from interactions and adverse reactions to alcohol, other prescribed or over-the-counter pharmacological agents, other medical procedures and food;

(c) Information to each service recipient that the goal of opioid treatment is stabilization of functioning;

(d) Information that detoxification from opioids over 30 to 180 days is a treatment alternative to long-term maintenance;

(e) Acknowledgement that the service recipient has been informed of the Facility's rules regarding service recipient conduct and responsibilities and continuing documentation of the service recipient's compliance with the Facility's policies;

(f) Acknowledgement that the service recipient has been informed of his or her rights (0940-05-42-.27);

(g) Information that at regular intervals, in full consultation with the service recipient, the program shall discuss the service recipient's present level of functioning, course of treatment and future goals; and

(h) Information that the service recipient may choose to withdraw from or be maintained on the medication as s/he desires unless medically contraindicated;

(4) A narrative biopsychosocial history completed within 30 days of the service recipient's admission;

(5) Medical reports including results of the physical examination; past and family medical history; review of systems; laboratory reports, including results of required toxicology screens; and progress notes, including documentation of current dose and other dosage data. Information in the medical record shall be entered by physicians and other licensed health professionals;

(6) Dated case entries of all significant contacts with service recipients, including a record of each counseling session in chronological order;

(7) Dates and results of case conferences for service recipients;

(8) The initial treatment plan, any amendments to the plan, reviews of the plan and the long-term, individualized treatment plan, including any amendments to that document and reviews of the plan;

(9) Documentation that services listed in the plan are available and have been provided or offered;

(10) Documentation that the service recipient was informed about the process and factors considered in decisions impacting service recipient treatment (for example, take-home medication privileges, changes in counseling sessions, changes in frequency of toxicology screens) or any other significant change in treatment, both positive and negative;

(11) A record of correspondence with the service recipient, family members and other individuals and a record of each referral for services and its results;

(12) Documentation that the service recipient was provided a copy of the Facility's rules and regulations and a copy of the service recipient's rights and responsibilities and that these items were discussed with her or him;

(13) A closing summary, including reasons for discharge and any referral. In the case of death, the reported cause of death shall be documented;

(14) A written fee agreement as detailed in Rules Chapter 0940-05-42-.06 dated and signed by the service recipient (or the service recipient's legal representative) prior to provision of any services. This fee agreement shall include an explanation of the financial aspects of treatment and the consequences of nonpayment of required fees, including the procedures for medically supervised withdrawal in the event the service recipient (or service recipient's legal representative) becomes unable to pay for treatment;

(15) Documentation of Central Registry clearance as required under these rules; and

(16) All other information and documents as required by the SOTA and these rules.

Notes

Tenn. Comp. R. & Regs. 0940-05-42-.07

Original rule filed September 20, 2012; effective December 19, 2012.

Authority: T.C.A. §§ 4-3-1601, 4-4-103, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, and 33-2-404.