How To Write A Daedas Quality Assurance

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1 Quality Assurance Standards Revised December 2000 South Carolina Department of Alcohol and Other Drug Abuse Services

2 Table of Contents INTRODUCTION... i CHAPTER 1: GENERAL GUIDANCE MISSION, CORE VALUES AND GUIDING PRINCIPLES OF DAODAS BACKGROUND ASSUMPTIONS PRIMARY PREVENTION PHILOSOPHY TREATMENT SERVICE PHILOSOPHY ASAM LEVELS OF CARE CHAPTER 2: ADMINISTRATIVE STANDARDS OUTCOME EVALUATION QUALITY IMPROVEMENT UTILIZATION REVIEW CLINICAL SUPERVISION CLINICAL RECORDS MANAGEMENT WAITING LIST MANAGEMENT PRIVILEGING HEALTH AND SAFETY EMERGENCY PREPAREDNESS AND DISASTER PLANNING FISCAL PROFESSIONAL LIABILITY CHAPTER 3: UNIVERSAL SERVICE STANDARDS SERVICE CLIENT ASSESSMENTS TREATMENT PLANNING CLIENT ENGAGEMENT AND RETENTION DOCUMENTATION APPENDIX A: DAODAS NEEDS ASSESSMENT AND SITE SELECTION PROCEDURE FOR NEW SERVICES APPENDIX B: DAODAS SITE SELECTION CRITERIA FOR PLACEMENT OF NEW OR EXPANDED SERVICES

3 INTRODUCTION The use of alcohol, tobacco and other drugs affects South Carolinians of all ages and from all walks of life. Problems resulting from these substances surface in our homes and schools, on our roads and highways, and in our workplaces and criminal justice system. Because of this, we, as citizens, pay the bill for the direct and indirect costs of substance abuse. In South Carolina, that bill adds up to approximately $2.5 billion per year. In other words, every person over the age of 18 in South Carolina spends about $1,000 each year to pay for the costs associated with the abuse of alcohol, tobacco and other drugs. These costs are reflected in artificially increased prices for all goods and services (because substance abusers are absent from work more often and are less productive when they are at work); higher taxes (for additional police and jails to deal with drunk driving and other drug-related arrests); property losses (due to thefts for drug money or automobile accidents); and higher healthcare costs (to cover the cost of abusers who use the healthcare system more extensively than nonabusers). DAODAS estimates that approximately 310,000 individuals in South Carolina are currently experiencing substance abuse problems that warrant intervention and treatment. During fiscal year 2000 (FY00), the state s 34 county alcohol and drug abuse authorities (recognized as the DAODAS provider system) provided direct services to just over 53,000 of these South Carolinians. Of these 53,000 individuals, 13,904 were women and 8,047 were young people. Treatment Needed v. Treatment Received 350, , , , , ,000 50, ,353 approx. 17% 93,152 approx. 13% 53,136 61,489 approx. 13% 13,904 8,047 Overall Women Youth Needed Treatment Services Received Treatment Services (Source: DAODAS Division of Management Information and Research; FY00 Unique Unduplicated Clients, DCSL Based, Special Demographics) i

4 CHAPTER 1 GENERAL GUIDANCE Mission, Core Values and Guiding Principles of DAODAS Mission To ensure the provision of quality services to prevent or reduce the negative consequences of substance use and addictions. Core Values Respect Integrity Dedication Guiding Principles Addiction is a preventable and treatable disease. The citizen-client is always the priority. The agency will: Provide statewide leadership and assistance on substance use and addiction issues; Work collaboratively with the provider system and other partners; Foster the special relationship between DAODAS and the provider system; Collaboratively ensure for the citizens of South Carolina an internal provider system of accountability; and Value its employees by providing recognition and professional development in a supportive working environment. Agency employees will be: Mission-focused Professional Culturally competent Team workers Proactive Effective communicators 1-1

5 Overarching Goals Clients in treatment achieve sustainable recovery. Citizen attitudes and behaviors change leading them: To refrain from use (abstinence); To refrain from abuse; and To reduce harm. Background Although the department s earliest predecessor dates back to 1957, the cabinet-level department known today as the South Carolina Department of Alcohol and Other Drug Abuse Services (DAODAS) was created by Act 265, The Government Accountability and Reform Act of DAODAS is the single state authority for alcohol and other drug abuse programming as originally authorized by Public Law of 1970 and Public Law of The department reports directly to the Governor and is responsible for advising the executive branch of state, the General Assembly and other state agencies regarding alcohol and other drug abuse issues. As the single state authority for alcohol and other drug abuse services, DAODAS has a responsibility to ensure that a statewide system of care exists. The DAODAS Quality Assurance (QA) Standards have been in effect since the late 1980s for the purpose of providing uniformed and continuous quality improvement guidelines for the county alcohol and drug abuse authorites as required by the South Carolina Department of Health and Human Services (DHHS) under Title XIX of the Social Security Act. As a funding source administering federal and state dollars to the county authorites, and as the state s alcohol and other drug abuse authority, DAODAS is mandated to administer a state quality assurance system based on state quality assurance standards for Medicaid and non-medicaid clients. The QA Standards are designed to protect the county authorities and its clients. They are not designed to micro-manage an agency or interfere with an agency s freedom to set higher standards. The QA Standards place emphasis on specific minimum requirements, while leaving the agency the option to exceed the minimum required standards. The QA Standards carve out and pinpoint the scope of the Team Coordinated County Review process and serve to reinforce the department s unique requirements of the county authorities in addition to standards that DAODAS has adopted from other national and state authorities. The QA Standards are designed to complement standards already required of providers by the South Carolina Department of Health and Environmental Control (DHEC), the American Society of Addiction Medicine (ASAM) and CARF The Rehabilitation Accreditation Commission. Throughout this document, it is assumed that the provider will comply with each of those standards, so they are not duplicated here, except in very special areas where quality of client care is at issue. These additional standards are intended to put a sharper edge on client quality of care for the state s citizens. 1-2

6 Assumptions With any set of standards, certain assumptions are made upon which the standards rely. This is certainly true with this manual. The following is a list of those assumptions: ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2) will continue to develop as the national standard for patient placement in the addictions field. DAODAS will recertify levels of care at predetermined intervals as appropriate. Team Coordinated County Reviews will serve as the primary mechanism for quality assurance review and recertification of levels of care. All program/service providers receiving DAODAS funding will maintain current licensure of facilities by DHEC for all levels of care at each site. This will be the department s expectation and requirement for all contracted providers. All programs/services receiving DAODAS funding will maintain national accreditation for required public services. All new services will be developed and implemented in accordance with the DAODAS Needs Assessment Procedure for New Services and Site Selection Criteria for Placement of New or Expanded Services (see Appendix A). These processes were adopted and published in the 1997 DAODAS Quality Assurance Standards. The department s Goals for Effectiveness have been established as increasing the effectiveness of treatment, and therefore increasing the likelihood of positive client outcomes. Primary Prevention Philosophy The misuse and abuse of alcohol and other drugs affect every community in South Carolina and create a tremendous burden on our society s resources. The impact of related health, social and economic problems cuts across race, age, gender and ethnic lines. Consequently, almost any individual or group is a potential participant in primary prevention programs. These programs are intended to lower the overall incidence of alcohol and other drug problems in the community and in society at large, and to reduce the human and economic cost of these problems. The public health model recognizes prevention as an ongoing process, not a single activity or event. This model promotes strategies that attempt to reduce both the supply of and demand for alcohol and other drugs. It provides a framework for a balanced, multidimensional approach that addresses the agent, host and environment. Primary prevention programming is an organized group of services designed to prevent the use, misuse or abuse of alcohol and other drugs. Primary prevention 1-3

7 programs include a broad range of activities designed to facilitate positive healthenhancing and substance-avoiding behaviors such as: developing an individual s strength and skills; facilitating community resources, support and commitments; and reinforcing societal norms that encourage positive behaviors. Primary prevention services are provided to a broad range of individuals and groups within the community, some of which are considered to be at high risk. It is important that prevention efforts are based upon needs within a given community. Primary prevention programs may occur in multiple systems: home, school and the broader community. Primary prevention takes its messages and services to where the people are, taking a proactive approach. These programs seek to access groups where they may be found, through networking, marketing and creative use of media. Treatment Service Philosophy Community-based alcohol and other drug counseling services are provided to individuals who experience some degree of problem or involvement with substance abuse. The continuum includes persons who: are at high risk of developing alcohol and other drug problems; are current abusers of alcohol and other drugs; have become dependent on these substances; or have family members who are experiencing problems with alcohol and/or other drugs. It is recognized that such problems affect a broad spectrum of society. These problems interfere with a person s ability to function effectively in the family, on the job or in the community. If substance dependence remains untreated, the individual and the whole family can become dysfunctional. Therefore, involvement of the family and significant others in the counseling process is integral to successful treatment. In a sense, the family may become the client, not just the identified alcohol or other drug abuser. Family members, too, are entitled to receive help for their own unresolved problems resulting from living in a family system affected by alcohol and/or other drug abuse. Community-based counseling relies on the belief that alcohol and other drug problems are treatable. Intervening as early as possible in the development of these problems is the most productive approach because there is a higher probability of preventing debilitating personal problems and societal costs. The goals of community-based counseling include: the elimination or reduction of harmful use of alcohol and other drugs; and positive lifestyle changes for the individual and the family. 1-4

8 Services are initiated when an individual or a family member seeks treatment, when a client is referred from another agency, or when a client is identified and referred through some formal intervention program. Since denial of one s dependency on substances is one of the symptoms of this disease, the likelihood of retaining clients in the treatment process is increased when family or outside sources provide leverage and/or support for the client to continue in services. Whatever the client s level of motivation or source of referral, voluntary or involuntary, the client may receive services. Community-based counseling allows the client to remain in his/her community, thus permitting treatment in the least restrictive environment appropriate to each client s needs. This provides appropriate service at a lower cost than inpatient settings would require. And, perhaps most importantly, it allows greater family involvement in the treatment process. Although most services currently take place in an agency office setting, they may be provided at other locations in the community under special circumstances. Counseling services begin with a thorough biopsychosocial assessment of the client/family needs, considering substance-related and other life problems. Medical stabilization and physical needs must be addressed before attending to the emotional and psychological issues that inevitably accompany substance dependency. For these reasons, alcohol and other drug counseling emphasizes a here and now approach. Services available to address the identified needs are crisis intervention; detoxification; treatment planning; individual, group and family counseling; referral for supportive services; and aftercare. Group approaches have been demonstrated to have greater effectiveness with these problems and are the preferred mode of treatment. Throughout service delivery, the client is actively involved in identifying his/her own needs and establishing treatment goals. Generally, counseling services continue until the client and counselor agree that these goals have been accomplished. Aftercare services and/or referral to supportive self-help groups are crucial to maintaining the gains made during treatment, since recovery is viewed as an ongoing lifetime process. ASAM Levels of Care DAODAS has adopted as its standard the levels of care for alcohol and other drug addiction developed by the ASAM PPC-2 published in As a ready reference, those levels of care currently available to contractors are outlined here: 1-5

9 Service Type Level of Care Examples Detoxification Level I-D Ambulatory Detoxification Without Extended On-Site Monitoring Outpatient Detoxification in Physician s Office or Home Healthcare Agency Level II-D Ambulatory Detoxification Day Hospital Service With Extended On-Site Monitoring Level III.2-D Clinically Managed Social-Setting Detoxification Programs Residential Detoxification Level III.7-D Medically Monitored Freestanding Detoxification Centers Inpatient Detoxification Level IV-D Medically Managed Intensive Inpatient Detoxification Psychiatric Hospital Hospital Inpatient Unit Treatment Services Level I Outpatient Services Office Practice, Behavioral Health Clinics, Primary Care Clinics, Substance Abuse Agencies Level II.1 Intensive Outpatient Treatment IOP Level II.5 Partial Hospitalization Day Treatment Programs Treatment Level III.1 Clinically Managed Low- Halfway House Intensity Residential Treatment Level III.5 Clinically Managed Therapeutic Community Medium/High Intensity Residential Treatment Level III.7 Medically Monitored Intensive Inpatient Treatment Center Inpatient Treatment Level IV Medically Managed Intensive Inpatient Treatment Acute Care General Hospital, Acute Psychiatric Hospital, Licensed Chemical Dependency Specialty Hospital OMT Opioid Maintenance Therapy Methadone Maintenance Program or LAAM Therapy Program NOTE: Other services are delivered based upon legislative mandate, which are not included in ASAM language on levels of care. 1-6

10 I. Outcome Evaluation CHAPTER 2 ADMINISTRATIVE STANDARDS A. Standard: The agency evaluates treatment outcomes for all client populations following discharge. Interpretive Guidelines: The standard requires that data useful for the purpose of evaluating treatment outcomes actually be gathered. Additionally, the agency must evaluate outcomes for all major populations of the persons served. Methodologies will include clients who have successfully completed services as well as those who unsuccessfully completed services. Methodologies based on representative or stratified sampling techniques may be used. B. Standard: The agency compiles a written summary and analysis of its outcome evaluation findings quarterly. Interpretive Guidelines: The intent is that the information be used to guide management decisions. The analysis should include data interpretation and how the agency will use the knowledge gained to improve services. C. Standard: The agency management reviews outcome evaluation data quarterly. D. Standard: The agency monitors client admissions and discharges to determine strategies that improve opportunities for client success. Interpretive Guidelines: The agency outcome evaluation methodology should directly monitor client dropout. Additionally, these findings should be used by agency management to determine if programmatic changes are in order. E. Standard: The agency gathers and analyzes outcome evaluation data for prevention programs. Interpretive Guidelines: Two evaluation formats are established in the DAODAS prevention contracts based on the prevention management plan: Impact Evaluation and Objective Evaluation. The Impact Evaluation can be outcome (or impact) in nature. This needs to relate to the indicator section of the management plan, which states why the program is involved in a specific endeavor and measures effectiveness. 2-1

11 The intent of the standard is to encourage the collection and objective evaluation of program performance data so that prevention programming may be progressively improved over time. Failure to conduct adequate evaluation of prevention programs is a much more serious problem than determining that a given program did not produce the desired or expected result. In comparison to the Impact Evaluation, the Objective Evaluation describes the programming offered, population served and other process measures relating to program efficiency. The Prevention Activities and Resource Management System (PARMS) is designed to facilitate the collection and retrieval of this data. II. Quality Improvement A. Standard: The agency has and implements a comprehensive, management-approved continuous quality improvement plan. Interpretive Guidelines: At a minimum, the plan should address current issues key to national accreditation, facility licensing, staff certification/licensure, utilization management, quality of care, risk management and efficiency. Programs vary widely in size and complexity, and the ideal organization of a continuous quality management plan will vary accordingly. B. Standard: The agency compiles a written quarterly summary and analysis of all key quality indicators. Interpretive Guidelines: The intent is that the information be used to guide management decisions. C. Standard: The agency management reviews key quality indicator data quarterly. D. Standard: Quality Assurance procedures shall be designed to ensure that a representative sample of both open and closed cases is reviewed no less than quarterly. Interpretive Guidelines: Case samples for Quality Assurance reviews must include all programs, services and clinicians. Additional care should be taken to include high-volume and high-risk cases. While no minimum sample size has been established, a minimum sampling of 10 percent of cases is recommended. 2-2

12 III. Utilization Review A. Standard: All open cases are staffed as often as needed to ensure optimal service design for each client. Interpretive Guidelines: The intent of the standard is that clinicians will readily seek and obtain expert clinical consultation from colleagues who are knowledgeable and experienced with the service population and treatment modalities in question for all open cases, in order to increase the likelihood that services are optimally designed for the individual client. B. Standard: All clients are placed in services in a manner consistent with the ASAM PPC-2 as modified and adapted by DAODAS. Interpretive Guidelines: Experienced addiction treatment professionals may vary moderately in their recommendations for treatment based upon differences in interpretation of the client s presentation. The intent is that placement decisions should take into account the severity of the client s illness, the full multiaxial diagnosis, salient unique characteristics of the client, as well as treatment options available. IV. Clinical Supervision A. Standard: All direct services staff shall receive clinical supervision at least monthly. Interpretive Guidelines: Clinical supervision may be provided using a variety of methods, including review of taped sessions, observation through a one-way mirror, direct observation or case review. Staffing is not considered clinical supervision. The exception to this standard is that clinical supervision for contractual ADSAP Group Leaders does not have to occur on a monthly basis. B. Standard: A clinical supervisor must be a certified National Certified Addiction Counselor II, a Master Addictions Counselor, a Licensed Professional Counselor, a Licensed Social Worker or a Licensed Psychologist. V. Clinical Records Management A. Standard: Clinical records must be secured by lock when not under the direct supervision of staff. 2-3

13 Interpretive Guidelines: Designated client record storage areas must have a locking door. Client records signed out of the record storage area are kept under direct supervision of staff and not left unsupervised. B. Standard: Access to clinical records is controlled so that the location and security of all clinical records are readily determinable through the record management procedures. C. Standard: The agency has a written policy and procedure for checking out clinical records from the central storage area. Interpretive Guidelines: A clear chain of custody for records that have been removed from the central records storage library must be documented by a check-out card or other device so that they can be readily located. D. Standard: Client records contain all information denoted in the current DAODAS Uniform Clinical Records (UCR) Manual and the DHHS Medicaid Alcohol and Drug Rehabilitation Services Manual. Interpretive Guidelines: Client records contain all required UCR information, DHHS Medicaid Alcohol and Drug Rehabilitation Services Manual or some other DAODAS-approved documentation methodology. E. Standard: Services are clearly individualized to the unique needs of the client. Interpretive Guidelines: Treatment must be matched to the individual client s needs, strengths and abilities. Consideration of each client s uniqueness (e.g., age, gender, etc.) is critical to optimal treatment outcomes. F. Standard: Services are clearly comprehensive, including case management for clinically relevant client complications beyond the scope of direct substance abuse treatment services. G. Standard: Admission, continuing care and discharge decisions are supported by clinical documentation. VI. Waiting List Management A. Standard: The agency has a written policy and procedure for documenting when service demand exceeds existing service capacity. This documentation includes a list of clients seeking services, date of application for service and date of entry into service. 2-4

14 Interpretive Guideline: DAODAS is to be notified when 90 percent of capacity is reached, and again at 100 percent of capacity. B. Standard: The agency provides individualized interim services to stabilize and support clients who are waiting for services. C. Standard: The agency compiles a written quarterly summary and analysis of waiting list data. Interpretive Guidelines: The intent is not simply that the information is collected, but instead that it is used to guide management decisions. D. Standard: The agency management reviews waiting list data quarterly. E. Standard: The agency has a written policy and procedure that provides admission priority to clients who are pregnant; are intravenous drug users; have tested positive for HIV infection; or have active tuberculosis. VII. Privileging A. Standard: The agency allocates privileges to all direct services staff based upon documented education, training and experience. Interpretive Guidelines: Privileging of new staff members should involve verification of academic credentials and professional credentials, and review of documented training and experience with the services and populations for which privileging is being considered. Privileging reviews of other staff should additionally consider changes in licensing or credentials, continuing education, staff performance, and progress toward certification for those in process. B. Standard: The agency reviews all privileges for all privileged staff as needed, but at least once every two years. Interpretive Guidelines: This involves a review of changes in licensing or credentials, continuing education, staff performance and experience with the services and populations for which privileging is being reconsidered. C. Standard: The agency maintains written documentation of each staff member s qualifications and privileges. Interpretive Guidelines: Privileging documentation on all staff should be individually maintained, separate from other personnel documents, and should include: copies of current licenses and certifications; copies of academic 2-5

15 transcripts to verify academic degrees; resumé describing relevant experience with the populations and services for which privileging is granted; training certificates; and a copy of a letter to the staff person delineating privileges. VIII. Health and Safety A. Standard: The agency conducts in-service training on universal precautions for all new hires during orientation. B. Standard: The agency conducts an in-service review training on universal precautions for all agency staff annually. C. Standard: The agency keeps surgical exam gloves and biohazard cleaning supplies readily available for staff use. D. Standard: The agency maintains records of training on universal precautions. E. Standard: The agency has a written policy and procedure for disposal of biologically hazardous waste. Interpretive Guidelines: Syringes, bodily excretions, and items contaminated with body fluids or other biological contaminants should be disposed of in accordance with established public health protocols. IX. Emergency Preparedness and Disaster Planning A. Standard: The agency has an evacuation plan, including prior formal written agreements with supporting agencies for transportation and housing, for all clients, to include inpatient and residential clients that cannot be discharged in an emergency. Interpretive Guidelines: The agency should execute formal contracts and memoranda of agreement with specific emergency medical transportation and residential care facilities. Because emergency transport resources are often over-extended during actual disasters, and some disasters can affect a wide geographic area (e.g., hurricanes and earthquakes), back-up resources for the primary evacuation plan should also be arranged. X. Fiscal The fiscal requirements are described in detail in the consolidated grant contract. The following two standards are included here to highlight their importance to DAODAS. 2-6

16 A. Standard: The agency shall have a written fee policy or policies that cover all client services by the agency, including the policy on indigent care. Interpretive Guidelines: The agency will ensure that a current copy of the fee schedule is on file at DAODAS. The fee schedule will be based on uniform assessment procedures to determine the client s ability to pay. The policy implementing the schedule will include the stipulation that no person shall be required to pay any fee prior to assessment screening for treatment services or assessment of financial ability to pay. The agency s policy shall be in compliance with the current DAODAS Policy on Indigency and Fee Assessment. B. Standard: The agency shall report revenue and expenditures to DAODAS accurately and completely. Interpretive Guidelines: All periodic reports of revenue and expenditures reported to DAODAS shall agree with those shown in local financial records. XI. Professional Liability A. Standard: The agency has a written policy on professional tort liability insurance coverage. Interpretive Guidelines: The agency is not required to provide liability insurance but must have a policy that explicitly states whether the agency extends full, partial or no professional liability coverage to its employees. Agencies may provide this insurance as a benefit, may subsidize purchase of individual employee policies or may elect to leave this entirely up to each individual staff member. B. Standard: During orientation, the agency informs all staff of the extent to which professional tort liability insurance is provided by the agency. 2-7

17 CHAPTER 3 UNIVERSAL SERVICE STANDARDS I. Service A. Standard: All clients admitted to services are assigned a primary case manager. Interpretive Guidelines: Clients admitted to services are assigned to a clinician who monitors and directs their treatment and notes progress and/or the lack of progress on a session note in the client s record. B. Standard: The service provider ensures that the person served is provided a written summary of the federal confidentiality law and regulations as required by 42CFR Part (a)(2). C. Standard: The service provider ensures that the quality improvement plan and efforts address all systems of the agency including administrative, service and program functions. Interpretive Guidelines: The service provider maintains documentation of service/program and administrative review results. The information may be maintained as part of minutes and reports of quality assurance activities. D. Standard: The service provider has a policy and procedure that delineates the method by which a client can obtain information in his/her clinical record. E. Standard: Clients are admitted to services in accordance with the ASAM PPC-2 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV-TR). Interpretive Guidelines: The clinical record contains documentation that supports the service provider using ASAM and DSM criteria appropriately. The sample of client records reviewed by DAODAS will be drawn from clients admitted to services after July 1, 1997, when ASAM PPC-2 was adopted. F. Standard: The service provider s grievance policy shall reflect the right of the client to appeal to DAODAS if the grievance is not resolved locally. G. Standard: Primary prevention services are based on an annual needs assessment in the local community that includes data from key stakeholders, 3-1

18 community surveys, demographic analysis, analysis of inferential indicators and review of client data. Interpretive Guidelines: The needs assessment considers ethnic, cultural, age and gender diversity of the community. It documents and prioritizes the needs in the community. Management plan activities are targeted at the prioritized needs revealed in the assessment. H. Standard: For clients being discharged from detoxification, halfway house and residential services: Upon discharge, the provider after the appropriate consent to release information has been completed must provide the clinical assessment, clinical assessment summary, discharge diagnosis, continuing care needs and any other pertinent information to the provider receiving referral for follow-up services. Documentation of this action will be in the client file. II. Client A. Standard: All clients receive an orientation to services that addresses, at a minimum, available services, fees and confidentiality. Interpretive Guidelines: Documentation, such as an orientation checklist or clinical service note, should be maintained in the client s record that shows that the client was made aware of what can generally be expected from the service provider. B. Standard: The service provider has taken steps to ensure that all materials used in counseling sessions are understandable to persons served. Interpretive Guidelines: Printed materials used by the agency are written at a reading level appropriate to the grade level of clients who enter services. The intent is for the service provider to utilize materials that improve the likelihood that the targeted client group s comprehension, participation and benefit from the counseling are maximized. Accommodations are to be made for clients with special needs, such as hearing-impaired, low literacy levels, clients with limited English-language proficiency, etc. C. Standard: Family or significant-other involvement in the primary client s treatment, where appropriate, is encouraged by the service provider. Interpretive Guidelines: In cases where family or significant-other involvement or lack thereof in treatment indicates a benefit to the client s progress in services, there is documentation in the client s record to indicate 3-2

19 that this option was pursued and the results noted. The client cannot be terminated due to the lack of family or significant-other involvement. D. Standard: Clinical documentation should adhere to standards set forth in the DHHS Medicaid Alcohol and Drug Rehabilitation Services Manual, DAODAS UCR Manual and ADSAP Operational Standards Manual. Interpretive Guidelines: It is expected that the session notes will contain specific content on what was shared and addressed by the client in the sessions, and its relevance to the client s progress toward treatment goals. General or global statements such as client is doing well or client participated in group are insufficient. The session note should contain sufficient detail to allow another clinician with little knowledge of the case to step in and provide treatment at any time. E. Standard: The client s age and gender are considered when treatment planning is done. Interpretive Guidelines: In cases involving women and adolescents, the documentation in the record supports placement in services unique to the gender and age of the client. III. Assessments A. Standard: The clinical assessment information forms the basis for the decision to refer or admit the client to services. Interpretive Guidelines: Based on a review of the clinical assessment, there is sufficient documentation to support that the client s present needs can be addressed through admission and participation in services. B. Standard: The master problem list developed from the clinical assessment is reflected in the treatment plan s goals and objectives. Interpretive Guidelines: The master problem list should document the area of the clinical assessment that the service provider intends to treat, monitor or refer. C. Standard: A full multiaxial diagnosis is completed on each client and is documented in the clinical record. Interpretive Guidelines: The diagnoses for all five DSM-IV-TR axes were documented by qualified staff. The diagnostic codes and names must be included for Axes I and II. For more information, please consult DAODAS 3-3

20 current UCR Instructions Manual and DSM-IV-TR manual. This does not apply to ADSAP clients referred to Level.05 services. D. Standard: The clinical assessment should include all six of ASAM PPC- 2 dimensions. Interpretive Guidelines: The client is rated on severity of symptoms in each of the six dimensions. The intent is to ensure that all facets of the client s life and clinical picture are reviewed as the basis for placement in a level of care. Please consult the ASAM PPC-2 for more information. IV. Treatment Planning A. Standard: Initial treatment plan is implemented upon the completion of the clinical assessment. Interpretive Guidelines: When the dates on the treatment plan and assessment forms are reviewed, they show that the time frame for completion of the treatment plan is consistent with this standard, and justifiable exceptions are supported by case management entries of client s broken appointments, reschedules, abrupt drop or dismissal from services. The intent of this standard is to promote quick transition of the client into the treatmentplanning phase and into services, thereby promoting client retention and client engagement. Therefore, based on the clinical assessment information, an initial treatment plan should be decided between the clinician and the client unless one of the justifiable exceptions that are noted in this interpretive guideline exist. The standard as written provides for adequate opportunity for the clinician and other clinical staff involved with the case to prepare to arrive at a treatment planning decision that leads to the development of an initial treatment plan, which is subject to change during subsequent sessions with the client if the client s needs change. B. Standard: Client input into the treatment planning process must be documented in the client s record. Interpretive Guidelines: Service notes contain statements that indicate that the client was allowed an opportunity to express opinions and choices about his/her needs and how they could best be addressed. C. Standard: Progress toward treatment plan goals is reviewed at each clinical contact and documented on service notes. Interpretive Guidelines: Client s progress or lack of progress on the treatment plan goals and objectives is addressed and documented at each clinical 3-4

21 contact. In addition, adjustments in treatment modality are noted when indicated, as well as whether the client needs to continue in the services ordered on the plan. D. Standard: The goals and objectives within the treatment plan are individualized, outcome oriented and measurable. Interpretive Guidelines: The client s goals and objectives should not be adapted from those of the program or service, but rather based on the client s primary identified needs, as indicated in the clinical assessment. It is expected that the goals and objectives will be written clearly, so that the client s accomplishment of the changes and improvements can be verified and observed by the service provider and other reviewers. E. Standard: Treatment plans are revised to reflect changes that occur with clients. Interpretive Guidelines: The clinician should ensure that the service being provided is listed on the client s treatment plan. F. Standard: Separate treatment goals and objectives are clearly identified for each specific service ordered on the treatment plan. Interpretive Guidelines: Group counseling and individual counseling, for example, must have different goals and objectives, primarily because they are different treatment modalities being employed to address different client needs. G. Standard: Treatment plan goals and objectives are revised when clients are moved to another level of care within the same service provider entity. Interpretive Guidelines: The clinician should make certain that the level of care being provided is listed on the client s treatment plan. V. Client Engagement and Retention. A. Standard: Clients will receive at least one unit of assessment within two days of intake. B. Standard: Clients with an assessment will have at least one unit of the following specified services (detox day, residential day, group counseling, individual counseling, intensive outpatient, day treatment, crisis management, intensive in-home services, therapeutic child care) within six calendar days from assessment. 3-5

22 C. Standard: Detox client episodes will be followed by at least one unit of group counseling, individual counseling, intensive outpatient or day treatment, or at least one day of residential service, immediately (one calendar day) after the end of the detox episode. D. Standard: Level III.5/III.7 residential care client episodes will be followed by at least one unit of group counseling, individual counseling, intensive outpatient or day treatment within six calendar days of the end of the residential episode. Interpretive Guidelines: The county provider should refer to its current DAODAS Consolidated Grant Attachment under Goals for Effectiveness for the specific performance requirements related to Client Engagement and Retention for the current fiscal year. VI. Documentation A. Standard: Session notes for each service provided to a client must be in the client s record within prescribed time frames. Interpretive Guidelines: The time frames set forth in the Performance Standards section of the DHHS Medicaid Alcohol and Drug Rehabilitation Services Manual should be followed for Medicaid and non-medicaid clients. B. Standard: Session notes must be signed by the clinician who provided the service. Interpretive Guidelines: When multiple clinicians are providing services to the same client, (i.e., co-leaders), it is sufficient for one clinician to enter documentation for the session. C. Standard: The client s discharge summary must be completed and in the client s record within eight working days of the staffing team s decision to discharge the client. D. Standard: Client discharge summary contains the appropriate information relative to justification for discontinuing services. Interpretive Guidelines: It is important that the discharge summary capture key information such as the client s diagnosis at discharge, client progress and areas the client will need to continue to work on in the continuing care plan. Details on completing discharge summaries are addressed in the DAODAS UCR Manual. 3-6

23 E. Standard: Documentation reflects coordination of care between case manager, family, community agencies, etc. Interpretive Guidelines: The service provider s case management documentation shows that internal and external staff involved with the client are working cooperatively together to provide timely and quality services indicated to address the client s needs. 3-7

24 APPENDIX A: DAODAS NEEDS ASSESSMENT AND SITE SELECTION PROCEDURE FOR NEW SERVICES This procedure is designed to gather the minimum information required to make an informed decision on whether to initiate a new service. As the process unfolds, additional information may be necessary and vital. The following information must be determined: 1. Does the proposed service fit within the vision and mission of DAODAS? 2. Is the development of the proposed service a priority for DAODAS? Has it already been identified as a priority or should it be? 3. Determine the level of need, and document these findings/justification. 4. Gather demographic and other relevant data on population to be served. 5. a) Referral Sources: Identify and assess willingness to cooperate b) Existing Providers: Identify and assess how well they are meeting the need c) At state level, identify existing or potential resources available to meet need for this service. 6. Is this/can this be cost effective? Review literature and research data on similar projects nationwide/regionally, etc. 7. Document other information gathered in the process that could be beneficial in later decision making regarding the development or implementation of this service. 8. Analyze the data and make a decision. A-1

25 APPENDIX B: DAODAS SITE SELECTION CRITERIA FOR PLACEMENT OF NEW OR EXPANDED SERVICES The following criteria are designed to be used as part of a request for proposal process in determining where new or expanded services will be placed. Potential sites would need to provide the following information to document their feasibility as a potential provider. I. Demonstrated Need A. Establish need for new service through needs assessment procedure B. Is service already available? 1. Where is it located? 2. Is it accessible? 3. Is it affordable? 4. Do we have existing relationship with other provider? 5. Do they have a quality service? C. Map need by county/region relative to population to identify where need is concentrated II. Resource Availability A. Qualified Staff 1. Assess current agency staff resources a. Is staff appropriately licensed/credentialed to provide the service? If a county authority, do staff credentials meet the minimum percentage for licensing and credentialing as established in the DAODAS and county authority standards? b. Do staff have appropriate training and skills for the new tasks? c. Is sufficient staff utilization capacity available to allow current staff to implement new service? 2. Assess potential use of external contract staff, volunteers or interns 3. Assess potential use of local organizations with money, people or time that are or want to be involved 4. Assess potential use of other providers, to include whether we can/want to access their service 5. Assess availability of necessary training B-1

26 B. Facilities 1. Existing agency facilities a. Will current facilities accommodate new service? b. Could available inadequate facilities be easily upgraded? Is funding available to upgrade the existing facility? 2. Are suitable external facilities available through cooperation with other organizations (e.g., outstationing)? 3. Do facilities meet requirements for physical accessibility? 4. Are transportation resources adequate? C. Political and Public Support 1. Political support 2. Funding support 3. Marketing resources 4. Local community support 5. Referring/cooperating stakeholder agency support III. Demonstrated Performance and Efficiency A. Assess Quality Assurance Plan and Implementation B. CARF or Other Accepted National Accreditation C. Utilization Rates D. Service Volume E. Outcome Studies F. Program Evaluation Studies G. Financial Stability H. Past Successes Implementing Other New Services I. Demonstrated Ability to Collaborate With Other Agencies J. Ability to Continue Program Once Start-up Funding Ends K. Success Recruiting and Retaining Competent Staff B-2