W. Va. Code R. § 69-7-32 - Post-Admission Assessment and Initial Plan of Care

32.1. Upon admission to an opioid treatment program, each patient shall undergo an initial post-admission assessment and the opioid treatment program shall develop an initial plan of care. The initial assessment and plan of care shall be completed within seven days of the patient's admission.

32.2. Post Admission Assessment.

32.2.a. The initial post-admission assessment shall consist of a comprehensive medical evaluation, which shall include, but not be limited to:

32.2.a.1. A comprehensive physical evaluation;

32.2.a.2. A comprehensive psychiatric evaluation, including mental status examination and psychiatric history;

32.2.a.3. A personal and family medical history;

32.2.a.4. A comprehensive history of substance abuse, both personal and family;

32.2.a.5. A tuberculosis skin test and chest X-ray, if skin test is positive;

32.2.a.6. A screening test for syphilis;

32.2.a.7. A Hepatitis C test;

32.2.a.8. An HIV test to the extent voluntarily elected by the patient; and

32.2.a.9. Other tests as necessary or appropriate (e.g., CBC, EKG, chest X-ray, pap smear, hepatitis B surface antigen and hepatitis B antibody testing).

32.2.b.A repeat, full toxicology screen may be completed at fourteen days after admission to identify whether the patient is using other drugs or substances, including opiates, methadone, amphetamines, cocaine, barbiturates, benzodiazepines and marijuana.

32.2.c. The initial post-admission assessment may include laboratory tests conducted by the opioid treatment program or by other reliable sources.

32.2.c.1. Laboratory tests that are not directly conducted by the program may be provided by the patient's primary care physician, other healthcare providers or by a medical clinic.

32.2.c.2. The opioid treatment program is responsible for obtaining and maintaining documentation of required laboratory tests performed by an alternative provider. Alternative providers may not supply toxicology screens unless they meet the required quality guidelines, content and timelines.

32.2.c.3. Tests not directly conducted by the opioid treatment program at admission shall have been conducted within the ninety days prior to admission in order to be considered a valid assessment of the patient.

32.3. Initial Individualized Treatment Plan of Care.

32.3.a. Within seven days of the admission of a patient, the opioid treatment program, in conjunction with the patient, shall develop an initial individualized treatment plan of care. Whenever possible and with patient permission, the development process shall include a non-addicted family member or significant other to assist in provision of accurate information and a full understanding and retention of instructions given to the patient.

32.3.b. The initial individualized treatment plan of care shall include:

32.3.b.1. Completion of program orientation;

32.3.b.2. Ongoing education regarding addiction, HIV/aids, hepatitis and communicable diseases;

32.3.b.3. Consistent program attendance, both for dosing and counseling sessions;

32.3.b.4. Elimination of withdrawal symptoms and opioid craving;

32.3.b.5. Cessation of illicit drug use; and

32.3.b.6. Resolution of other issues unique to the needs of the individual.

Notes

W. Va. Code R. § 69-7-32