DHS 75.24(9)(a)1.
1. A written consent for treatment, which shall be signed by the prospective patient before admission is completed.
DHS 75.24(9)(a)2.
2. Information concerning communicable illnesses, such as sexually transmitted infections, hepatitis, tuberculosis, and HIV, and shall refer patients with communicable illness for treatment when appropriate.
DHS 75.24(9)(a)4.
4. A method for informing the patient about, and obtaining the patient's signed acknowledgment of having been informed and understanding all of the following:
DHS 75.24(9)(a)4.b.
b. Patient rights and the protection of privacy provided by confidentiality laws.
DHS 75.24(9)(a)4.c.
c. Service regulations governing patient conduct, the types of infractions that result in corrective action or discharge from the service, and the process for review or appeal.
DHS 75.24(9)(a)4.f.
f. Information about the cost of treatment, who will be billed, and the accepted methods of payment if the patient will be billed.
DHS 75.24(9)(a)4.g.
g. Sources of collateral information that may be used for screening and assessment.
DHS 75.24(9)(b)
(b) If the patient is seeking treatment related to opioid use, and the service does not provide medication-assisted treatment for patients with opioid use disorders, the service shall provide information about the benefits and effectiveness of medication as an effective treatment for opioid use disorders. If the patient is not already receiving medication treatment, the service shall obtain the patient's written consent to participate in non-medication treatment, shall provide a referral to a service that offers medication-assisted treatment for opioid use disorders.
DHS 75.24(10)(a)(a) A service shall prioritize admission in the following order:
DHS 75.24(10)(b)
(b) When a waitlist exists for services for pregnant women, the service shall either initiate interim services or notify the department within 2 business days.
DHS 75.24(10)(c)
(c) When a waitlist exists for services for individuals who inject drugs, the service shall either initiate interim services or notify the department within 14 business days.
DHS 75.24(11)(a)(a) Clinical staff of a service, operating within the scope of their knowledge and practice, shall assess each patient through interviews, information obtained during intake, counselor observation, and collateral information.
DHS 75.24(11)(b)
(b) The service shall promote assessments that are trauma-informed.
DHS 75.24(11)(c)
(c) If a comprehensive clinical assessment has been conducted by a referring substance use treatment service and is less than 90 days old, the assessment may be utilized in lieu of conducting another one.
DHS 75.24(11)(d)
(d) Information for the assessment shall include the following:
DHS 75.24(11)(d)1.
1. The clinical staff's evaluation of the patient, and documentation of psychological, social, and physiological signs and symptoms of substance use and/or mental health disorders, based on criteria in the DSM.
DHS 75.24(11)(d)2.
2. The summarized results of all psychometric, cognitive, vocational, and physical examinations provided as part of the assessment.
DHS 75.24(11)(d)4.
4. Documentation about the current mental and physical health status of the patient.
DHS 75.24(11)(d)5.
5. Psychosocial history information shall include all of the following areas that relate to the patient's presenting problem:
DHS 75.24(11)(d)5.i.
i. Other factors that appear to have a relationship to the patient's substance use and physical and mental health.
DHS 75.24(11)(d)6.
6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following:
DHS 75.24(11)(d)6.d.
d. Consultation with the patient's physician or other medical or behavioral health provider.
DHS 75.24(11)(d)6.e.
e. Consultation with department of corrections or child protective services when applicable.
DHS 75.24(11)(d)7.
7. Level of care recommendation based on ASAM or other department-approved placement criteria.
DHS 75.24(11)(e)
(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
DHS 75.24(11)(f)
(f) The clinical staff's recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.
DHS 75.24(11)(g)
(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.
DHS 75.24(11)(h)
(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
DHS 75.24(11)(i)
(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.
DHS 75.24(11)(j)
(j) In the event that the assessed level of care is not available, a service shall:
DHS 75.24(11)(j)1.
1. Document accurately the level of care indicated by the clinical assessment.
DHS 75.24(11)(j)2.
2. Indicate on the treatment plan what alternative level of care is available or agreed upon.
DHS 75.24(11)(j)3.
3. Identify on the treatment plan what efforts will be made to access the appropriate level of care, additional services or supports that will be offered to bridge the gap in level of care, and ongoing assessment for clinical needs and level of care review.
DHS 75.24(11)(k)
(k) For assessments completed by a substance abuse counselor in-training or a graduate student QTT, the assessment and recommendations shall be reviewed and signed by the clinical supervisor within 7 days of the assessment date.
DHS 75.24(11)(L)
(L) For a patient receiving mental health services under s.
DHS 75.50 or
75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria is not required.
DHS 75.24(12)(a)(a) A service shall have written policies and procedures for referring patients to other service providers and for coordinating care with other providers.
DHS 75.24(12)(b)
(b) Policies and procedures shall include a description of follow-up activities to be completed to support that recommended care is received.
DHS 75.24(13)(a)(a) Clinical staff of a service shall develop a treatment plan for each patient.
DHS 75.24(13)(b)
(b) A patient's treatment plan shall represent an agreement between the service and the patient regarding needs identified in the clinical assessment, the patient's identified treatment goals, and treatment interventions and resources to be applied.
DHS 75.24(13)(c)
(c) When feasible, the treatment plan shall be developed in collaboration and with input from the patient's family or significant other, or other supportive persons identified by the patient.
DHS 75.24(13)(d)
(d) The treatment plan shall be signed by the patient, the primary counselor, and other behavioral health clinical staff, identified in the treatment plan.
DHS 75.24(13)(e)
(e) A treatment plan completed by a substance abuse counselor in-training or a graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the development of the plan or the next treatment plan review, whichever is earlier.
DHS 75.24(13)(f)
(f) The content of the treatment plan shall describe the identified needs and specify individualized treatment goals that are expressed in behavioral and measurable terms.
DHS 75.24(13)(g)
(g) The treatment plan shall specify each intervention applied to reach the treatment goals.
DHS 75.24(13)(h)
(h) The treatment plan shall be reviewed at the interval required by the patient's level of care or based on the patient's needs and clinical indication. The review shall be documented with a summary of progress and the signature of the patient and primary counselor.
DHS 75.24(13)(i)
(i) The treatment plan review shall include an updated level of care assessment which follows ASAM or other department-approved placement criteria and recommends continued stay, transfer, or discharge.
DHS 75.24(13)(j)
(j) An updated treatment plan shall be established during the review if there is a change in the patient's needs, goals, or interventions and resources to be applied. The updated treatment plan shall be signed by the patient, the primary counselor, and any other behavioral health clinical staff identified in the treatment plan.
DHS 75.24(13)(k)
(k) Treatment plan reviews and updates completed by a substance abuse counselor in-training or graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the review and update.
DHS 75.24(13)(L)
(L) For patients with co-occurring disorders receiving services under ss.
DHS 75.50,
75.51,
75.52,
75.54,
75.55,
75.56, and
75.59 service shall assign dually-credentialed clinicians whenever possible. When this is not possible, the service shall ensure that mental health needs and substance use needs are included in the treatment plan, and met by appropriately credentialed personnel.
DHS 75.24(13)(m)
(m) For a patient receiving mental health services under s.
DHS 75.50 or
75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria and review is not required.
DHS 75.24(14)(a)(a) A service shall have a written policy and procedure that outlines the structure for clinical consultation.
DHS 75.24(14)(b)
(b) Clinical consultation applies to all clinical staff of a service.
DHS 75.24(14)(c)
(c) Clinical consultation shall be documented in the patient's case record.
DHS 75.24(14)(d)
(d) Clinical consultation for unlicensed staff shall be completed with a clinical supervisor and shall be documented with the clinical supervisor's signature. Clinical consultation for licensed professionals may occur with a clinical supervisor or another licensed professional who is a staff of the service.
