Standard Operating Procedures Required For All Agencies Authorized to Provide Substance Abuse Services for DWI Offenders. Each facility shall develop and maintain a written Standard Operating Procedures Manual which must contain all of the following elements at minimum. (Revised 06/15/2013)
Element A: Narrative Description of Services Documentation. 1.) Your SOP shall contain a document that provides the description of your facility and the services it will provide. This document must address the following elements only. a.) List all DWI services your facility intends to offer. b.) List all screening and/or assessment instruments(s) that your facility will use. c.) List all evidence-based practices to be used in your facilities education and/or treatment programs (e.g. Motivational Interviewing, MET, CBT, CRA, etc.). d.) Indicate the dual diagnosis designation for the programs you will provide as found in ASAM PPC-2R (i.e. Addiction Only Services, Dual Diagnosis Capable, Dual Diagnosis Enhanced). Element B: Provide and maintain samples of forms your agency will use in connection with providing Substance Abuse Services for DWI Offenders. 1.) Your SOP must Include a sample of each of the following forms your agency will use. a.) Release of Information Form b.) Clinical Interview / Assessment Interview Form c.) Person-Centered Treatment Plan Form d.) Service Note Form e.) Discharge Summary Form f.) Client Services Contract Form g.) Client Rights / Grievance Form
Standard Operating Procedures for DWI Services: A. Each facility shall develop a written Standard Operating Procedures Manual for the DWI Services their agency will provide. This manual shall contain each policy listed below. Policy 1: DWI Assessor and Treatment Provider Qualifications Policy The qualifications necessary for individuals to conduct DWI specific assessments. (Refer to (G.S. 122C-142.1) The qualifications necessary for individuals to provide substance abuse treatment. The exceptions to the Practice Act. Your facility s plan to prevent violations to these statutes. Policy 2: DWI Assessment Documents Policy List and describe the documents that are necessary to conduct a DWI assessment. (Refer to 10a NCAC 27g.3809) List and describe the documents that need to be transferred to another agency in order for a client to obtain services from that agency. (Refer to 10a NCAC 27g.3809) Policy 3: Client Service Contract Policy List and describe what information needs to be included within the Client Service Contract. (Refer to 10a NCAC 27g.3809). Policy 4: E508 Policy Describe the NC DWI Services E508 policy. (Refer to the e508 policy on the state DWI Services website: http://www.ncdhhs.gov/mhddsas/dwi/providers/policies.htm)
Policy 5: Records Retention / Ceasing of DWI Services Policy The record retention period for all DWI records. (Refer to 10a NCAC 27g.3811 and Division Records Retention and Disposition Schedule for State and Area Facilities: (http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm10-3retentionupdated5-05.pdf) The process for ensuring proper processing/transferring of DWI client records in the event that your agency ceases the provision of DWI services. (Refer to 10a NCAC 27g.3811) Policy 6: Drug Testing Policy Describe how your facility will implement drug testing. Describe what your facility will charge for drug testing that is completed during the course of treatment. (Note: Clients may not be charged for drug tests completed as part of the assessment) Policy 7: Confidentiality / Security of Client Records Policy Define what information you must relay to clients in reference to federal confidentiality laws and regulations, and how this information will be relayed. Describe what structures you will have in place to protect and maintain the security and privacy of client records and information (paper and electronic), including where records are kept and who has access. Define how your agency will ensure proper application of 42 CFR Part 2, HIPPA, 45CFR Parts 160 & 164 and re-disclosure guidelines. Refer to both: 10a NCAC 27g.3807, and SAMHSA s Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination Technical Assistance Publication (TAP) Series 11, Chapter 11, Confidentiality: www.kap.samhsa.gov/products/manuals/taps/11.htm Policy 8: Client Rights / Grievance Policy Describe your agency s policy for ensuring client rights and addressing client grievances (including grievance resources). (Refer to Client Rights Rules in Community Mental Health, Developmental Disabilities, and Substance Abuse Services, 10A NCAC 27D.0201 http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm95-2clrights7-03.pdf)
Policy 9: Clinical Supervision Policy Define how your agency will ensure that Registrants, CSAC-I, CSAC, CCJP or Provisional Licensees are receiving the clinical supervision that is required by NCSAPPB. (Refer to the North Carolina Substance Abuse Professional Practice Board (NCSAPPB), Information Concerning Practice Protection: http://www.ncsappb.org/resourcessteve/index.htm) Policy 10: Professional Resources Policy List the professional resources that are required at your agency to address clinical staff needs. 1. NC MH/DD/SAS Laws (NCGS 122C) 2. Rules for MH/DD/SAS Facilities and Services (APSM 30-1) 3. Diagnostic and Statistical Manual of the APA (DSM-V) 4. American Society of Addiction Medicine Patient Placement Criteria (ASAM, PPC 2R) 5. Confidentiality Rules (APSM 45-1) 6. Service Records Manual (APSM 45-2) 7. Client Rights Manual (APSM 95-2) 8. Policies and Procedures for your agency 9. Copy of the Code of Conduct Policy 11: Fee Policy List the fee scale for DWI services your agency will provide. Define the fees that are required to be paid to the State each year for Reauthorization and for ADETS services. Policy 12: Out of State Review Policy (If Applicable) Describe how your agency will handle the processing of DWI offenses that require out of state reviews. Attach copies of any documents that you intend to use and/or send to the client when conducting an Out of State Review.