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SECTION 5
OTP PROGRAM DESCRIPTION AND PLAN
Introduction and Overview
This "Program Description" is intended to supplement the organization's administrative and clinical policies and procedures and provide additional information relative Porter-Starke Services Opiate Treatment Program. The description has been prepared specifically to conform to national accreditation standards that require such a plan; however, the plan also provides a practical purpose in that it articulates a more detailed description of "treatment-specific" policies and procedures. The plan has the same "force and effect" as formal policy and all employees of the PSS OTP have the responsibility for implementation of the plan.
Program Mission Statement
The Porter-Starke Services is dedicated to enhancing the quality of life in our community through prevention, treatment, education and research. We believe in the disease concept of addictive illness and will treat our patients with dignity and respect in all phases of their treatment experience. Because of this belief, we will focus our clinical practice in terms of disease. We strive always to improve the quality of the lives of the patients we serve. We will strive to institute current research findings in our delivery of services. We will also be a resource to the community we serve by helping to educate the public on the disease of addiction and advocating at all times the value of treatment in improving the welfare of our community. Our staff will at all times keep our mission statement as the guiding principle in their work.
Values
In our interactions with our patients, each other and members of the communities in which we work, we will treat everyone with dignity and respect. We value:
Our clients, employees and partners.
Commitment to high quality services that are delivered
effectively.
Integrity, compassion and responsibility in every encounter.
Consistent care for children and adults with serious mental illness and chronic addiction.
Open communication, validated business standards and
transparent operations.
Creativity and innovation for continuous, measureable quality improvement.
We value honesty, integrity, hard work and adhere to the highest ethical standards of addiction treatment. We embrace the concepts of personal and professional accountability in the workplace and will always strive to treat others as we would like to be treated.
Program Description
The Porter-Starke Services Opiate Treatment Program subscribes to the definition of opiate or opioid addiction as consistent with that of other addictive disorders: a pattern of pathological use marked by the physiological and psychological inability to abstain from substance use, impairment in social functioning, emotional and psychological health and stability, behavioral stability, interpersonal relationships and occupational functioning. Pathological use is often characterized by a myriad of problems or manifestations that include increased incidences of hospitalization, medical problems, arrests, increased involvement with the criminal justice system, loss of friends or negative changes in family and interpersonal relationships, inability to maintain employment, increased financial problems, "acting out" through anti-social behavior and at a more personal level, loss of self-esteem, self-confidence, and a decreased sense of personal responsibility. The PSS opioid treatment program focuses exclusively on those patients with an addiction to opiates/opioids. We attempt to help them break out of their disruptive and self-destructive lifestyles. A major programmatic focus is toward an initial stabilization effort intended to halt the dysfunctional lifestyle of the narcotic addict.
Treatment Philosophy
We believe that treatment services should be delivered in a person-centered manner that respects the dignity and self-worth of every patient; services that are relevant to the needs of each person served and the diversity of our patient population. Person-centered care has its focus on the person with an illness and not on the disease in the person. To achieve truly person-centered care we need to understand how the patient experiences his or her situation if we are to understand the patient’s behaviors and symptoms. This is implemented in the program through an in-depth understanding of the patient’s life circumstances and preferences, combined with up-to-date evidence-based knowledge about individualized treatment. We believe that treatment and recovery are very personal experiences with distinct physical, mental, emotional and spiritual components that may differ significantly from patient to patient. We believe that each patient has a right to be fully and completely
informed about the services we provide and our approach to treatment. Most importantly, we believe that each patient brings unique life experiences to the treatment environment which plays a vital role in treatment planning, service delivery and discharge/transition planning. Additionally, we are convinced that addiction is a family disease and it is best treated within that context. Therefore, we encourage and support - through fully informed patient consent - the involvement of family members and/or significant others in educational programs offered by the organization and, in actual counseling sessions and treatment activities. Finally, we recognize our moral and ethical responsibility to provide the highest quality treatment services that hold the greatest promise of successful outcomes for our patients.
Program Goals
Porter-Starke Services Opiate Treatment Program has established the following annual "clinical goals" for its opioid treatment program. These are in addition to the organizational goals developed as part of the organization's annual strategic planning process:
1. At least 70% of all patients will maintain a drug-free lifestyle following one year in treatment;
2. At least 75% of all patients will be employed after one year
of treatment or enrolled in educational or vocational pursuits;
3. At least 90% of all patients will maintain and demonstrate
socially acceptable behavior and be productive members of
society after one year in treatment;
4. At least 95% of all patients will have at least one randomly scheduled urine drug screen conducted during each month in treatment;
5. At least 95% of all patients will be seen by their case managers/counselors according to their treatment phases;
6. 100% of all patients who show a positive urinalysis for illicit drug use shall be seen by a counselor as part of a therapeutic intervention;
7. 100% of all patients who elect the detoxification/medically supervised withdrawal process will receive supportive counseling and a viable referral for aftercare/continuing care support.
Scope of Services
The Porter-Starke Services Opiate Treatment Program offers opioid treatment services intended to assist patients in achieving optimal treatment outcomes and support accomplishment of the organization's objectives which will be reviewed annually:
Methadone maintenance treatment at $13 per day; self-pay
Medically-supervised withdrawal; and
Detoxification from other opiates, utilizing methadone
Provide take homes to eligible patients
The program uses an interdisciplinary approach for addressing the personal or social needs of the patient and capitalizes on both in-house resources and/or referral to outside agencies and service providers. Specifically, the PSS OTP treatment services are designed and implemented to: (1) support the recovery, stabilization and well-being of patients; (2) enhance and promote the quality of life for all patients served through a harm reduction model; (3) reduce symptoms associated with opioid use and dependency and build individual resilience as part of a relapse prevention strategy; (4) teach and model ways to help patients restore and/or improve their daily functioning and "life skills"; and (5) support patients as they re-integrate into their communities of choice, families, and/or support systems. On a more personal level, PSS OTP's services are intended to help patients develop enhanced self-esteem, self-confidence, self-responsibility and honesty. The organization's treatment program is comprised of four distinct components that are grounded in sound medical and case practices: (1) individual and group counseling as prescribed; (2) involvement of family members and/or significant others in counseling and/or educational services as needed with appropriate patient consent; (3) psycho-educational activities intended to educate patients about addictive disorders and the toxic effects of drugs (including alcohol); and (4) affiliation with self-help and other community resources. At the heart of the program is an organizational commitment to individualized treatment tailored to meet the specific needs of each patient; and as evidenced by person-centered assessments and decisions made upon individual need, personal and societal functioning and drug-free urinalysis testing results rather than artificial benchmarks such as dosing level and/or length of time in treatment.
At the core of the program is the belief that dosing levels should not be determined by agency policy or any other artificial "dose cap". For clarification, the organization does not generally support, encourage or endorse the idea of dose caps or dosing levels that are dictated by anything other than (1) the individualized needs of the patient and (2) the professional judgment of the Medical Director. Methadone is administered in Porter-Starke Services Opiate Treatment Program for craving reduction and for the suppression of withdrawal symptoms; the use of methadone is not authorized for analgesic purposes, i.e., pain reduction, in the Porter-Starke Services Opiate Treatment Program clinic.
Referral Sources
In most cases, the PSS OTP staff can accommodate any request for service that falls within the scope of the organization's capability and scope of practice for its professional staff members. However, in the event that a patient presents for services at a Porter-Starke Services Opiate Treatment Program clinic and cannot be accommodated for any reason, the medical staff or the counselor will facilitate a referral to another provider who can accommodate the patient's need for services. This includes staff assistance to help the patient access other services, providers and provider organizations. Referrals are routinely made, as appropriate for to treatment for people with medical problems and mental health problems as well as to (1) local advocacy groups, (2) consumer groups, (3) self-help and Twelve Step groups, and (4) other avenues of support that may be available in the local community, e.g., other community based mental health centers, organizations that provide employment and job assistance, etc. Individuals who have co-occurring health issues, including: medical problems, mental health problems, are using or abusing multiple drugs, using or abusing alcohol, have or need testing for HIV or other sexually transmitted diseases or infectious diseases will be referred to the appropriate service provider. The PSS OTP Clinic is required to maintain a current listing of community providers as a way to ensure that anyone seeking services at the PSS OTP clinic has access - either direct or through referral - to a full continuum of behavioral health and addiction treatment and/or other ancillary and support services. The Program Director at the clinic is responsible for arranging for and maintaining formal letters of agreements (generally referred to as "referral agreements") with individual providers and/or other provider organizations as a way to ensure that PSS OTP patients have access to a broad range of health care services and to ensure that all direct care staff are aware of all community resources.
Porter-Starke Services Opiate Treatment Program maintains that effective treatment often depends on collaboration and coordination between providers. Therefore - and to the greatest extent allowed by applicable law, ongoing communication between both internal and external providers is encouraged and supported. Documentation of referrals and/or other communication between providers will be maintained as a critical component of continuity of care.
Populations to be served:
The Porter-Starke Services Opiate Treatment Program will provide services to persons with an opioid dependency. The pregnant patient will be considered high risk and will receive priority services. We have also identified three more primary groups of patients that the organization considers as special populations: (1) patients who do not have full mobility and/or use some sort of assistive device for mobility purposes, (2) patients who are sight and/or hearing challenged, and (3) patients who do not speak English as their primary language of choice. For clarification, this categorization should not be construed to mean that patients with other special needs do not receive services from PSS OTP clinic; this simply means that the three patient categories mentioned above represent the majority of patients who can legitimately be categorized as meeting the definitions established by national accreditation bodies for special populations. In most cases, the PSS OTP staff can accommodate any request for service that falls within the scope of the organization's capability and scope of practice for its professional staff members. However, in the event that a patient presents for services at the Porter-Starke Services Opiate Treatment Program and cannot be accommodated for any of the reasons identified above, the therapist will facilitate a referral to another provider who can accommodate the patient's need for services. This includes staff assistance to help the patient access other services, providers and provider organizations. Referrals are routinely made, as appropriate, to (1) local advocacy groups, (2) consumer groups, (3) self-help and Twelve Step groups, and (4) other avenues of support that may be available in the local community, e.g., other community based mental health centers, organizations that provide employment and job assistance, etc. The PSS OTP Clinic is required to maintain a current listing of community providers as a way to ensure that anyone seeking services at a PSS OTP clinic has access - either direct or through referral - to a full continuum of behavioral health and addiction
treatment and/or other ancillary and support services. The Program Director at the clinic is responsible for arranging for and maintaining formal letters of agreements (generally referred to as "referral agreements") with individual providers and/or other provider organizations as a way to ensure that PSS OTP patients have access to a broad range of health care services and to ensure that all direct care staff are aware of all community resources.
Porter-Starke Services Opiate Treatment Program maintains that effective treatment often depends on collaboration and coordination between providers. Therefore - and to the greatest extent allowed by applicable law, ongoing communication between both internal and external providers is encouraged and supported.
Resources, Staffing and Organizational Structure
The most critical - and important resource - is the human resource capability of the organization. The leadership of Porter-Starke Services Opiate Treatment Program is tasked with providing adequate resources (staff, facilities, equipment, supplies, inventory, etc.) to ensure quality care and continuity of services. Specifically, the leadership is responsible for maintaining adequate staffing levels to (1) meet the established outcomes for patients served at the clinic, (2) ensure the health, safety and welfare of the clinic's patient population, (3) provide continuity of care during incidents of unplanned staff absences due to vacations, medical emergencies, pregnancies, etc, and (4) meet the expectations of the organization as they pertain to quality and delivery of care. The Program Director - as a member of the organization's leadership - is primarily responsible for the recruitment and retention of staff members at the clinic level. The Program Director is responsible for identifying and reporting any trends in personnel turnover that could adversely affect quality and/or continuity of care. For clarification, such reports are submitted to the Vice-President of Clinical Services on an "ad hoc" basis.
The clinic operates in a classic "line and staff" manner with the Program Director responsible for daily administrative and program matters (staff supervision, compliance with state and federal methadone regulations, fiscal accountability, etc.). The Program Director receives programmatic and managerial guidance from the Vice-President of Clinical Services. Similarly, the clinic has a licensed medical practitioner who serves as the Medical Director.
The Medical Director conducts initial physical examinations, initial dose titration, and is responsible for approving subsequent dose changes including any take-home schedules. The Medical Director is the attending physician for all patients receiving care. As such, he or she supervises all staff in areas directly related to medical practice and treatment but is expected to consult with other staff members in matters pertaining to a patient's psychosocial functioning as documented and known by the counselor assigned to the case. All medical practitioners are appropriately licensed and credentialed in accordance with the laws of the state. The Medical Director receives programmatic guidance from the Program Director and or Vice-President of Clinical Services. The Vice-President of Clinical Services delegates operational authority. The CEO has ultimate responsibility for treatment services and organizational direction in accordance with organizational policy and procedures, state and federal laws, national accreditation standards. Porter- Starke Services Opiate Treatment program staff ratios will be one therapist for every 55 patients.
Nursing staff have direct access to the Medical Director for medical matters and for those matters directly related to the practice of their professions. This does not, however, relieve the medical staff from adherence to PSS OTP operating policies and procedures. Subject to applicable state laws and regulations, nurses at Porter-Starke Services Opiate Treatment Program clinics receive medical supervision from the Medical Director and administrative and operational supervision from the Program Director or Vice-President of Clinical Services. The Program Director and Vice-President of Clinical Services retain their authority and responsibility to supervise all staff personnel for "non-medical" issues. All staff members are expected and encouraged to work as a true interdisciplinary team with a goal of providing the highest quality opioid treatment services. In fact, this arrangement provides the flexibility to respond directly to any issue of care that may arise in the delivery of treatment services and, has proven to be a viable model for service delivery.
The Human Resources Department of Porter-Starke Services is responsible for ensuring that all staff members are appropriately licensed and credentialed and undergo any required background and/or other checks as required by the federal government and state opiate treatment authority.
Service Location
Porter-Starke Services Opiate Treatment Program currently provides services in Porter County, Indiana.
Hours of Operation
Services are offered at times that best meet the needs of the majority of patients served at each clinic but include the availability of "after hours" emergency/crisis intervention services. The PSS OTP clinic is open seven days a week (Monday through Sunday); The operating hours at PSS OTP clinic is determined based on the needs of patients but adhere - with minor deviations - to some "base" operating hours:
Monday through Friday
6:00 a.m. to 2:00 p.m. (Operating Hours)
6:00 a.m. to 10:00 a.m. (Dosing Hours)
Saturday, Sunday, Holiday’s
6:00 a.m. to 8:00 a.m. (Operating Hours)
6:00 a.m. to 8:00 a.m. (Dosing Hours)
Screening
The organization's initial contact with a prospective patient may be a telephone contact, a face to face contact in which the person is simply inquiring about the program and/or services offered or, may occur when the person presents for admission. In any case, the staff member who initially communicates with the prospective patient must always assess:
(1) the person's eligibility for admission as based on presenting problem, apparent need for services, and legal eligibility;
(2) appropriateness of the person's admission to the program based on the organization's specialized expertise and experience; (3) availability of funding sources or the person's ability to pay for her/his own treatment, and (4) an initial determination regarding the potential benefit/gain to the person if he/she is admitted to treatment, i.e., whether the organization can provide the services actually needed by the person. For clarification, the screening process will include (1) an interview/discussion with the prospective patient or in some cases, a community referral source, (2) the identification and documentation of the immediate and urgent needs of the prospective patient, and (3) as appropriate, a pre-admission visit to the clinic by the prospective patient.
In the event that a person is found ineligible for admission/services, (1) the person is informed as to the reason for her/his ineligibility,
(2) the referral source, if applicable and with the consent of the prospective patient, is informed of the reason for the ineligibility determination, and (3) recommendations will be made for alternative services or disposition.
Admission Criteria and Process
The PSS OTP provides services to patients of both genders, age 18 and above, who meet the diagnostic criteria for opioid dependence as specified in the current version of the Diagnostic and Statistical Manual for Mental Disorders, American Psychiatric Association. PSS OTP provides services without regard to age, gender, ethnicity, race, sexual orientation, culture, religion or spiritual belief. For every patient admitted to Porter-Starke Services Opiate Treatment Program for treatment, the admission process will document:
a. A government issued photographic I.D. card to assure that the individual is providing accurate identity information; b. The patient has been addicted to an opioid drug; c. Became addicted at least one (1) year prior to admission; d. Voluntarily is choosing treatment; e. Provides written informed consent to treatment. (440 IAC 10-4-15 (a)) (a) evidence of tolerance to an opioid; (b) current or past physiological dependence for at least one year prior to admission; and (c) a history of multiple and daily self-administrations of an opiate. PSS OTP admits and provides services to women who are pregnant and has special policies pertaining thereto that are provided elsewhere in this program description. As exclusionary criteria, PSS OTP does not provide services to persons under the age of 18 under any conditions.
Virtually all patients who meet the organization's admission criteria for opioid dependency are admitted to treatment as long as they have the ability to pay; however, admission preference is given to women who are pregnant. Generally speaking, all patients who have previous treatment episodes in the PSS OTP clinic may be re-admitted to treatment as long as they meet the admission criteria for opioid dependency upon presentation for admission. However, the organization reserves the right to deny re-admission to patients who have been previously discharged due to assaultive and/or aggressive behavior. In such cases, the Medical Director, Program Director and/or therapist will consult with other staff regarding the case and make a decision regarding the re-admission decision.
The Program Director will be the ultimate decision-making authority in those cases in which consideration is being given to the re-admission of a patient who was previously discharged for behavioral reasons.
Exemptions From Minimum Standards For Admission
The PSS OTP admission procedures recognize that in some cases, it is both necessary and clinically prudent to waive the admission criteria of physical dependence or one-year history of addiction when the prospective patient meets one of the following criteria: (a) the person has been released from a criminal justice/penal facility within six months; (b) the person has been recently released from a chronic care facility and is at risk of relapse; (c) the person has been previously treated and is at risk of relapse; (d) pregnant women who do not exhibit objective signs of opioid withdrawal or physiological dependence; (e) is an intravenous drug user and, (f) if the person is HIV positive.
Medical Evaluations and Physical Examinations
The Medical Director is responsible for ensuring that the manner in which medical functions may be delegated to other staff is clearly articulated in all protocols. As part of the admission process, a physical evaluation is conducted by the Program Physician and fully documented. A complete/full medical examination and indicated/related lab work is completed within fourteen (14) days of admission by the physician or the authorized healthcare professional. The licensed registered nurse will complete intake and periodic physical evaluations including annual TB testing. It is required that all patients receive a copy of "About Methadone and Buprenorphine" at the time of the initial evaluation. At a minimum, and annually, the medical examination will include (a) an instant opiate urine drug screen and a urine specimen submitted to a CLIA lab for complete admission drug screening; (b) a TB test and chest x-ray if the skin test was ever previously positive; (c) a screening for HIV and AIDS, Hepatitis C, sexually transmitted and communicable diseases, and (d) other laboratory tests as clinically indicated and approved by Porter-Starke Services Opiate Treatment Program and/or other tests required by state regulatory/licensing agencies. Laboratory tests that are not conducted "on site" will be provided by the patient's primary care physician, other health care provider or by another medical clinic. In the event that a patient presents for admission and indicates that he/she has had any or all of the above tests conducted prior to presenting for admission, such tests must
have been conducted within the past 90 days - with supporting documentation provided to the PSS OTP staff - or the tests will have to be repeated as part of the admission process. The only exception to this policy pertains to urine drug screens; urine drug screens will be conducted on all patients admitted/re-admitted to the Porter-Starke Services Opiate Treatment Program clinic.
Every patient seeking admission to a PSS OTP clinic will be oriented to the program in accordance with the organization's Policy on Patient Orientation contained elsewhere in this manual.
Written Record
The written record of each patient includes, but is not limited to, the following: a. The patient's written informed consent to treatment; b. Written confirmation that the patient voluntarily chose opioid addiction treatment; c. Documentation that the patient received a clear and adequate explanation of all relevant facts concerning the use of opioid treatment medication d. Documentation that the patient received information on Patient rights, including the right to confidentiality, Patient responsibilities, and the OTP's grievance procedure. The written record of each patient also includes the results of: a. The physical evaluation; b. The history and physical examination; c. The substance abuse assessment; d. The biopsychosocial history. The written record of each patient also includes the patient's medication dose history, including the current dose. The written record of each patient also includes the results of medical tests, including drug testing. The written record of each patient also includes: a. The current treatment plan; b. Progress notes addressing treatment plan goals. The written record of each patient includes documentation of each contact with the patient and the patient's family. The written record of each patient also includes information on any and all referrals to services not provided by the OTP. Records of discharged patients are kept for at least seven (7) years after the patient's last contact with the OTP.
Treatment Procedures and Guidelines
The following procedures and guidelines describe the organization's fundamental approach to the delivery of opioid treatment services:
Assessment:
The OTP will maintain a master record for each patient and conduct an initial - and subsequent assessments as needed - on each
patient served in a manner that is respectful and considerate of the patient's specific needs. Assessment results will be shared with the patient, family members, appropriate staff and others on a "need to know" basis and other persons as dictated and authorized by the patient. Assessments will only be conducted by staff members with the appropriate training (including training on the organization's intake forms, processes and tool) and professional credential as required by law in Indiana. Additionally, assessments will be conducted by staff members who are knowledgeable about and competent to assess the specific needs of persons with substance abuse/dependency problems. In addition to information obtained from the patient, assessments will also include information from family members and/or significant others, friends and peers, and other persons on a "when appropriate and when permitted" basis. It is recognized that in some cases, patients will disclose information that must be reported to governmental entities or regulatory agencies. In such cases, the patient will be notified as soon as it becomes apparent to the "assessor" that reportable information is being disclosed.
The primary assessment - generally referred to as the "intake" or “written record” in most substance abuse treatment organizations, will include, at a minimum, the following information: the patient’s written informed consent to treatment and written confirmation that the patient voluntarily chose opioid addiction treatment. Documentation will show that the patient voluntarily chose opioid addiction treatment and documentation that the patient received a clear and adequate explanation of all relevant facts concerning the use of opioid treatment medication. Documentation will show that the patient received information on Patient rights, including the right to confidentiality, patient responsibilities, and the OTP’s grievance procedures. Documentation may also include; (a) presenting issues from the perspective of the person served; (b) Urgent needs, including: 1. Suicide risk; 2. Personal safety; 3. Risk to others. (c) personal strengths; (d) individual needs; (d) patient abilities or interests; (f) patient preferences; (g) previous behavioral health history including; 1. Diagnostic history; 2. treatment history; (h) Mental status; (i) Medication, including: 1. current or previously used medications; 2. Efficacy of current or previously used medication 3. Medication allergies or adverse reactions to the medications; (j) physical health information, including: 1. health history, 2. current health needs; (k) Co-occurring disabilities, disorders, and medical conditions. ; (l) current level of functioning; (m) Pertinent current and historical life information, including his or
her: (1) age. (2) Gender, sexual orientation, and gender expression. (3) Culture. (4) Spiritual beliefs. (5). Education history. (6) Employment history (7) Living situation. (8) Legal involvement. (9) Family history. (10) Relationships, including families, friends, community members, and other interested parties. (n) History of trauma: (1) That is: (a) experienced. (b) Witnessed. (2) Including: (a) Abuse. (b) Neglect. (c) Violence. (d) Sexual assault. (o) Use of alcohol, tobacco, and/or other drugs. (p). Risk-taking behaviors. (q) Literacy level. (r) Need for assistive technology in the provision of services. (s) Need for, and availability of, social supports. (t) advance directives, when applicable. (u) Psychological and social adjustment to disabilities and/or disorders. (v) Resultant diagnosis(es), if identified. Whenever possible - and as allowed and authorized by the patient - the assessment process will also include information from family members, friends and peers and other appropriate and permitted collateral sources.
The intake/assessment will be completed in accordance with specific time lines established by the state opiate treatment authority (SOTA) in Indiana. Unless specifically limited by state mandate, the length of time allowed for completion of intake documentation will be maximized to allow consideration of all available data and therefore, to optimize the treatment planning process.
This "policy" recognizes that many patients who present for treatment are initially unable to participate in treatment planning because of neurological and intellectual impairment due to drug use; and, that symptom stabilization/mitigation may be necessary before the patient can reasonably be expected to participate as an active member of the treatment team.
The intake/assessment process will result in the preparation of an interpretive summary that is based on the assessment data, used in the development of the treatment plan, and identifies any co-occurring disabilities/disorders that should be addressed in the treatment planning process. Periodic re-assessments will be conducted as clinically indicated and as determined by the primary counselor or other member of the treatment team.
In preparing interpretive summaries, clinical staff members will utilize the following guidelines:
1. Interpretive summaries will not be a mere recapitulation (summary or re-statement) of the information gathered during the assessment process.
2. Interpretive summaries provide an opportunity for the clinical staff to demonstrate their clinical skill and expertise in interpreting the information gathered during the assessment process to answer some fundamental questions about the patient's anticipated response to treatment services.
3. All interpretive summaries shall attempt to answer the following questions in narrative form:
a. What are the "central themes" that will most likely need to be addressed during this patient's treatment?
b. What unique challenges/problems can be anticipated in providing services to this patient?
c. What are the patient's unique assets (strengths, skills, abilities, support system, etc.) and how can they be used to maximize treatment effectiveness?
d. What counseling/treatment approach (or combination of services) will most likely yield the most effective treatment outcome for this patient?
e. What specific problem areas should be included on the patient's treatment plan?
f. What is the patient's prognosis for initiating recovery/sobriety if he/she fully complies with the recommended treatment protocol and actively works toward completion of his/her treatment goals and objectives?
The importance of the interpretive summary cannot be overemphasized as it serves as the foundational basis for the treatment planning process and more critically, for the development of individualized treatment plans that provide a true model for quality care.
Person-Centered Plan
At the heart of the PSS OTP approach to the person-centered treatment plan is the belief in and commitment to the active involvement of patients in the process - including a major role in determining the direction of the treatment plan. To the greatest extent possible, treatment plans should reflect that the planning process is "patient centered."
A written person-centered treatment plan will be developed with the active participation of the person served; and, the involvement of the family/legal guardian of the person served, when applicable and permitted. The development of the person-centered plan is prepared by using the information from the assessment process; and is based upon the person’s strengths, needs, abilities and preferences. The person-centered plan will be focused on the integration and inclusion of the person served into his or her community; the family, when appropriate; natural support systems; as well as other needed services. The person-centered treatment plan - and more specifically, the goals and objectives outlined on the plan - will be communicated to the patient in a manner and in terms that are understandable to him/her and, a copy of the plan will be provided to the patient for retention.
The initial person-centered plan must be developed with the counselor and with the active participation of the patient as required by the various state regulatory/licensing agencies and should include: a description of services to be offered immediately, provisions for additional/ongoing assessment, identification of a staff member responsible for coordinating care and a discussion of how those objectives will be accomplished. The person-centered plan must be completed no later than 7 days after admission to treatment (or, as otherwise required by state OTP rules and regulations). Person-centered treatment plans should include the following components; a. the identification of the needs or desires of the person served through: (1) goals that are expressed in the words of the person served and when necessary, clinical goals that are understandable to the person served. The goals are reflective of the informed choice of the person served or parent/guardian.
The person-centered treatment plan should be formally reviewed initially and updated at least monthly within the first 90 days as part of routine "staffing" or "case " or "quality review" sessions. After 90 days the plan is updated as appropriate, but not less than annually to ensure continuing relevance to the patient and his/her needs.
The person-centered treatment plans developed in the PSS OTP clinic shall include the following specific service or treatment objectives: (a) reflective of the expectations of the person served and, (b) the treatment team. They should reflect that the patient is fully informed about his/her treatment and treatment options, appropriate to the patient's (a) age, (b) development, (c) culture and ethnicity, (3) responsive to the patient's disabilities, (4) clearly understandable to the patient, (5) measurable, (6)achievable, (7) time specific and (8)appropriate to the treatment setting; (c) identification of the specific interventions, modalities, and/or services to be used. (d) frequency of specific treatment interventions; and (e) information on, or conditions for: (1) any needs beyond the scope of the program. (2) referrals to additional services. (3) transition to other community services. (4) community based services options available to persons in long-term residential support programs (5) available aftercare options, when needed. (f) When applicable, the identification of: (1) legal requirements (2) legally imposed fees. Person-centered plans are reviewed periodically with the person served to : (a) reflect current issues (b) maintain relevance (c) modify goals, objectives, and interventions, when necessary (d) maintain visitation plans and/or court orders, when applicable. Progress toward achievement of service or treatment objectives for the person served is (a) documented (b) utilized for service or treatment improvement (c) communicated to the person served. When assessment identifies a potential risk for dangerous behaviors, a personal safety plan: (a) is completed (1) with the person served (2) as soon as possible after admission. (b) includes: (1) triggers (2) current coping skills (3) warning signs (4) preferred interventions necessary for (a) personal safety (public safety (5) advanced directives, when available.
When the patient has a co-occurring disorder or disabilities and/or co-morbidities (a) the person-centered plan specifically addresses these conditions in an integrated manner (b) services are provided by personnel, either within the organization or by referral, who are qualified to provide services for persons with concurrent disabilities and/or disorders. If the services are provided to persons who have intensive medical needs: (a) the person-centered plan specifically
addresses how services will be provided in a manner that ensures the safety of the person served (b) services are provided in accordance with all regulatory requirements.
Progress notes should (a) document: (1) progress toward achievement of identified: (a) objectives (b) goals. (2) significant events or changes in the life of the person served (3) the delivery and outcome of specific interventions, modalities, and/or services that support the person-centered plan. The person-centered plan is (1) signed and (2) dated.
Services for Women
As reflected in the "Admission Criteria" section of this description, Porter-Starke Services Opiate Treatment Program provides services to women and to women who are pregnant. The organization recognizes the increased organizational responsibility and legal liability that potentially results from providing opioid treatment services to pregnant women. Therefore, the following guidelines and procedures have been adopted at all PSS OTP clinics as a way to: (1) maximize treatment effectiveness to that special population; (2) minimize medical and physical risks to the patient and her unborn children; (3) fully comply with the guidelines
established by SAMHSA/CSAT and adopted by the three accrediting organizations approved to accredit opioid treatment programs; and (4) ensure that opioid treatment services provided in PSS OTP clinic is consistent with generally accepted standards of medical care for the treatment of pregnant women.
The special practices and procedures pertaining to services for women and pregnant women at the PSS OTP clinic include:
1. Once admitted to the treatment program and as clinically appropriate, female patients will receive counseling regarding health issues specific to women (including reproductive health issues), domestic violence, and sexual abuse.
2. The process for assigning primary counselors to female patients will consider the special needs of those patients.
3. With respect to women who are pregnant and opioid-addicted and receiving methadone therapy, clinic personnel shall: (a) maintain the patient who becomes pregnant during treatment on the pre-pregnancy dosage, if effective, or changing the dose carefully - especially during the third trimester; (b) apply the same dosing principles as used with any other non-pregnant patient, if applicable; (c) ensure that the initial dose for a person who is newly admitted and pregnant reflects the same effective dosing protocols used for all other patients; (d) consider that the pregnancy may change metabolism, resulting in a need to adjust the methadone dosage; (e) ensure the subsequent indication and/or maintenance dosing strategy reflects the same effective dosing protocols used for all other persons served; (f) monitor the methadone carefully - especially during the third trimester; (g) collaborate with an OB/GYN or outside family physician on appropriately related medical issues; and.
4. All clinical and medical procedures involving women who are pregnant shall:
adhere to accepted medical standards of care for women who are pregnant;
adhere to accepted medical standards regarding adequate dosing strategies;
include initiation of opioid treatment services on a priority basis; and
include access or referral to prenatal care/services, pregnancy/parenting education, and postpartum follow-up.
5. In the event that a pregnant woman is denied admission to
the PSS OTP clinic, the reasons for the denial will be clearly
documented. For clarification, the organization reserves the right to refuse admission to any women who is pregnant if, in the professional judgment of the Medical Director, the administration of methadone poses a potential risk of harm or injury to the woman and/or her unborn child.
6. All patients who are pregnant will receive education on detoxification, medically supervised withdrawal.
7. Every patient who is pregnant will be encouraged to obtain prenatal care, prenatal education, and postpartum through a referral recommendation to other appropriate health care providers.
8. When providing detoxification/medically supervised withdrawal services to pregnant patients whose withdrawal symptoms cannot be eliminated, the clinical staff shall make appropriate referral arrangements to other health care providers, up to and including inpatient medical programs. Such referrals shall be documented in the patient's record;
10. Patients who have co-occurring health and psychosocial issues will be referred as needed to an appropriately qualified and credentialed provider.
Services to Pregnant Women
1. When providing detoxification (and medically supervised withdrawal) services to women, clinic staff will insure that counseling is provided, as appropriate, for specific women's issues. As part of this requirement, the Program Director will insure to the greatest extent possible that counselor assignment is based on the needs and desires of the patient.
2. When detoxification services are provided to women who are pregnant, the Medical Director will ensure that they will receive services within 48 hours: (a) ensure that all detoxification services adhere to accepted medical standards of care for pregnancy; (b) ensure that all doses of methadone are consistent with generally accepted dosing strategies for treating pregnant women; (c) ensure that the facts and risks regarding detoxification/medically-supervised withdrawal during pregnancy are fully explained as part of the patient orientation process; (d) ensure that pregnant
women are given priority in initiating opioid treatment. If they are not provided services within 48 hours the physician will ensure that a referral will be made within 48 hours;
(e) determine the individual and appropriate dosages for methadone to ensure stabilization; and (f) ensure that pregnant patients have full access to educational materials on pre-natal care and post-partum follow-up and (g) as appropriate, referrals for other pre-natal care. In the event that appropriate prenatal care is not available through referral or the pregnant woman cannot afford care, the staff will provide basic materials on pre-natal, maternal, physical and dietary care. Documentation that such materials have been provided will be included in the patient's record. In the event that the woman refuses such information and/or any referral for direct prenatal care, the clinic staff will document the refusal.
3. All patients who are pregnant will receive education on detoxification, medically supervised withdrawal including the impact of both on the health and welfare of unborn children;
4. Every patient who is pregnant will be encouraged to obtain prenatal care and prenatal education through a referral recommendation to other appropriate health care providers. In the event that a pregnant patient does not follow-up on the referral for such care, clinic staff shall document in the patient's record that the referral was made but the patient refused to follow-up;
5. When providing detoxification services to pregnant women whose withdrawal symptoms cannot be eliminated, referrals to inpatient medical programs will be made as expeditiously as possible;
6. Urine and other toxicological tests will be used to determine the absence of drugs in persons receiving detoxification services;
7. No unsupervised or take-home medications will normally be prescribed/administered for patients receiving detoxification services of less than 30 days duration. The organization's policy on take-home medications will apply for patients receiving detoxification services of more than 30 days duration;
9. The organization's protocol for detoxification is: medically supervised withdrawal is (a) is well tolerated by the patient and consistent with sound medical practices; (b) implementation of a higher stabilizing dose in the event of
impending relapse; (c) increases in counseling and other support services upon admission to the program as a way to provide enhanced support for the patient; and (d) continuing care after the last dose of methadone (in the case of medically supervised withdrawal);
10. In the event that a patient attempts to discontinue detoxification services against medical advice, the clinic staff shall: (a) document those efforts taken to avoid discharge; (b) document the reasons the patient is seeking to discontinue services; and (c) ensure that the patient record remains "open" for at least 30 days following discharge;
11. All detoxification services will be provided in the manner that is consistent with generally accepted medical standards of care and opioid addiction treatment. Services will consider the physical and emotional comfort of the patient and will include admission or readmission to maintenance treatment, if indicated. Additionally, detoxification services will include counseling to assist and encourage patients to explore other modalities of care - including admission to inpatient, residential or outpatient substance abuse treatment - following discharge from the detoxification program. Such counseling will be designed and offered to motivate patients to continue to receive services or, to develop a plan for recovery following discharge.
Pregnant Patients' Financial Responsibilities
All patients of child bearing potential being admitted to treatment are afforded full and accurate information regarding patient responsibilities in the event of pregnancy during treatment with methadone. It is the position of Porter-Starke Services Opiate Treatment Program that pregnancy does not absolve patients of their responsibility to pay for treatment. Further, the safety of medically supervised withdrawal during pregnancy has been established based on clinical experience defining the process as an evidence-based optional procedure.
Medication
Porter-Starke Services Opiate Treatment Program is keenly aware of its legal, moral and ethical obligations to maintain positive controls over all medication prescribed and administered by its physicians. In addition to the specific guidelines contained in PSS OTP's Policy on Medication, the following procedural guidelines are intended to ensure that all medications administered by the
organization are controlled, prescribed and dispensed in accordance with all applicable federal and state regulations:
1. As a governing principle, the methadone used in the treatment of opioid addiction will be prescribed and administered in sufficient doses to achieve: (a) the desired patient response; (b) freedom from adverse abstinence symptoms for the desired length of time; and (c) blockade of euphoria if opiates, such as heroin, are ingested/injected.
2. The methadone prescribed and administered in the PSS OTP clinic for the treatment of opioid addiction will be approved by the U.S. Food and Drug Administration for the treatment of opioid addiction. Physicians employed by Porter-Starke Services Opiate Treatment Program will prescribe methadone only for the purposes for which this medication was manufactured and marketed and will not prescribe medication for "off label" purposes. The patient will be referred to their physician or another physician if other medication is needed to address other diagnosis.
3. The methadone will be closely managed and monitored to ensure secure storage, accurate dosing and follow-up accounting for unsupervised doses as required by existing DEA regulation.
4. When dispensing methadone, the Medical Director or other staff member who is legally authorized will: (a) order the medication and/or dosage change; (b) sign for the medication and/or dosage change; (c) ensure that each dose is recorded in the patient record; and (d) ensure that an accurate inventory of all medication is maintained in stock.
5. Medication documentation will include: (a) the signature or initials of the qualified staff member administering the medication; (b) the exact number of milligrams of the medication dispensed; and (c) the daily totals of the substance dispensed;
6. Initial doses of methadone administered to patients in the PSS OTP clinic will (a) be individually determined by a physician after the initial examination and (b) will not exceed 30 mg of methadone or, when applicable, a total dose for the first day that does not exceed 40 mg. Unless otherwise prescribed by the physician, an initial total dose of methadone does not exceed 40 mg for the first day. In the event that the initial total daily dose of methadone exceeds 40 mg, documentation is made in the record of the person served by the physician or other qualified medical staff member to indicate that the 40 mg dose did not suppress the patient's abstinence symptoms.
7. The Medical Director/physician will determine all maintenance doses of methadone to meet the individualized needs of patients and, will consider adjusting and increasing the dosage when the drug screening shows evidence of opioid use.
9. All doses of methadone administered in the PSS OTP clinic will be: (a) individualized based on the needs of the individual patient; (b) reviewed and updated periodically as required and clinically indicated; and (c) based primarily on the patient's response to the methadone or the urge to use illicit/abuse licit drugs.
10. The adjustment of dosages will always be guided by specific clinical "outcomes" that include: (a) cessation of withdrawal symptoms; (b) cessation of illicit opioid use as measured by negative drug tests and reduction of drug-seeking behavior; (c) establishment of a blockade dose of an agonist that blocks the euphoric effects of opioids and prevents the desired sensations when heroin is used; (d) absence of problematic craving as measured by subjective report and clinical observations; and (e) absence of signs and symptoms of too large an agonist dose after an interval adequate for the patient to develop complete tolerance to the blocking dose.
11. Clinic procedures will ensure that patients have the ability to discuss dosing levels with appropriate staff members. There will be no procedural or organizational encumbrances to such ability. All discussions between patients and staff members about dosing will be documented in the patient's record.
12. PSS OTP's policy regarding take-home medications is as follows:
a. Decisions regarding take-home medication must include input from the Medical Director/physician in consultation with the interdisciplinary treatment team but with the clear understanding that the Medical Director/physician is the ultimate and final authority over such matters.
b. All decisions regarding take-home medications must include consideration of the patient's rehabilitation and functional status.
c. The Medical Director will determine, in
consultation with the Program Director, if a patient is eligible for unsupervised, take-home medications. Before considering a split-dosing regimen for a patient, the take-home eligibility of the patient must be established. If the patient is not eligible, then the process for requesting exceptional unsupervised doses must be followed.
d. All Medical and clinical decisions regarding take-home medications will be based the federal government's "eight point criteria" for giving take-home medications and will specifically consider: (1) the absence of recent abuse of drugs (opioid or non-narcotic and alcohol), (2) regular program attendance,
(3) absence of serious behavioral problems at the clinic, (4) absence of known recent criminal activity (including drug dealing), (5) stability of the patients home environment and social relationships, (6) the length of time in comprehensive maintenance treatment with absence of illicit drug use, (7) assurance that take-home medications can be safely stored at the patient's home, and (8) consideration of the rehabilitative value of decreasing the frequency of clinic attendance against potential risks for diversion.
e. In accordance with the Code of Federal Regulations (CFR) and specifically, CFR 42 Part 8, "Certification of Opioid Treatment Programs", the amount of take-home medication will be based on the clinical judgment of the Medical Director/physician in consultation with the other members of the treatment team and under normal circumstances. Patients will attend clinic daily and will not generally exceed a single take home dose each week during the first 90 days in treatment; two doses per week in the second 90 days of treatment; three doses per week in the third 90 days of treatment; a maximum six-day supply of take-home medication in the remaining months of the first year in treatment;
a maximum two-weeks supply of take-home medication after one year of continuous treatment. PSS OTP's policy recognizes that 42 CFR Part 8 also provides that, "Any patient in comprehensive maintenance treatment may receive a single take-home dose for a day that the clinic is closed for business, including Sundays and State and Federal holidays" and that, "Treatment program decisions on dispensing opioid treatment medications to patients for unsupervised use beyond that forth in the general provisions, Paragraph 8.12 (i) (1) shall be determined by the medical director." For clarification, this is in addition to the take-home dose limits described in paragraph (e) above. Porter-Starke Services Opiate Treatment Program will strictly adhere to those state-imposed requirements as a condition for continued state licensing and adherence to state requirements for opioid treatment programs;
f. As a matter of policy, the goal of medical withdrawal at the PSS OTP clinic includes determining a schedule of withdrawal that is well tolerated by the patient and is in accordance with sound medical practices, assurances that voluntary withdrawal would be discontinued and maintenance resumed in the event of impending relapse, reviews of the results of a recent pregnancy test and planning with the patient for counseling, other support services, or continuing care after medical withdrawal;
13. When medical withdrawal is conducted against medical advice, clinic staff will document those efforts taken by the staff to avoid discharge and the reasons the patient is seeking discharge from the program. In such cases, the patient record will remain in an active status for at least 30 days;
14. Prior to the beginning of "administrative withdrawal", the clinic staff shall document their efforts regarding referral or transfer of the persons served to a suitable, alternative treatment program;
15. Clinical documentation will be maintained regarding the condition of the patient during withdrawal to include symptoms of medical distress, symptoms of emotional distress, significant signs of opioid abstinence or withdrawal, actions taken by the staff (including those to avoid discharge) and patient progress. All documentation will adhere to all "state-specific" requirements regarding clinical documentation; and,
16. All counseling services provided will include attempts to motivate the patient to continue services following medical withdrawal.
Transition, Discharge and Recovery Support Services
Porter-Starke Services Opiate Treatment Program recognizes that patients with addictive disorders often require services from other providers after discharge or, in conjunction with a transition to another level of care. Such services are necessary to support the advances made in treatment and to address clinical problems and needs that are beyond the scope of PSS OTP professional staff. Historically, such services have been referred to as "aftercare" or "continuing care". For clarification, the term "transition planning" is used herein to refer to that planning that is conducted when it is anticipated that a patient will be discharged - either voluntarily or involuntarily - from the program and/or transferred to another level of care; and is referred to another service provider for ancillary or continued services. The following guidelines will govern transition planning and/or the referral to other agencies, organizations and service providers:
1. Transition planning will be initiated with the patient at the earliest possible point in the treatment planning and/or service delivery process.
2. Within seven (7) days following patient discharge, the discharge summary will be completed by the counselor. The discharge summary shall specify the reason(s) for treatment termination and shall be filed in the inactive patient chart.
3. A written transition plan will be prepared with each patient leaving the program to ensure continuity of services and will identify the patient's current progress in his/her recovery, any gains achieved as a result of receiving services from PSS OTP and individual strengths, needs, abilities and preferences upon discharge/transition.
4. Transition plans will be developed with the active participation of the patient, treatment team members and
others as applicable and as authorized by the patient, i.e., family members, significant others, legally authorized representatives, referral sources, and persons from other community services.
5. Transition plans will identify the person's needs for support systems or other types of services to assist in continuing his/her recovery or well being.
6. As applicable, transition plans will include information on current medications that the patient is taking.
7. Transition plans will include referral source information such as contact name, telephone number, locations, hours and days of service availability.
8. Transition plans will include information on options available if symptoms of relapse occur or if emergency services are necessary.
9. Copies of transition plans will be provided to all persons who participate in the development of the transition plan, as permitted and as applicable.
10. When the transition plan indicates the need for additional services or supports, staff members will be identified who will be responsible for follow-up after transition. Such staff members will be responsible for maintaining the continuity and coordination of services, helping the patient determine if additional services are needed and offering to provide, coordinate or refer to needed services as necessary.
11. In the event of an unplanned transition, counselors will be identified who will follow up with the patient to determine if he/she needs further services and provides or refers to such services when possible.
12. When a person is discharged or removed from a program for aggressive/assaultive behavior, the staff conducts follow up within 72 hours to attempt to ensure linkage to appropriate care, if so desired by the patient.
It is recognized that effective transition planning requires knowledge of local community resources since patients often require the services of providers other than Porter-Starke Services Opiate Treatment Program. Therefore, each clinic maintains a community resource directory that lists the appropriate contact information on other providers and provider organizations in the local community. The community resource directory is made available to all clinic staff as a way to ensure that the services provided by PSS OTP represent one part of a larger continuum of care.
Licensure and National Accreditation
The Porter-Starke Services Opiate Treatment Program clinic is licensed by the state regulatory/licensing authorities in the state of Indiana. The Porter-Starke Services Opiate Treatment Program is required to be nationally accredited by an accrediting body approved by SAMHSA/CSAT. Information on the accreditation status of the clinic is available from the Program Director.
Legal Compliance
As a matter of policy, the Porter-Starke Services Opiate Treatment Program will operate in full and complete compliance with all federal and state laws and regulations pertaining to the delivery of opioid treatment services. Toward that end, the organization has developed a comprehensive agency responsibility program to monitor compliance, and to ensure that the organization takes proactive steps to comply with all legal authority and to prevent and detect any illegal or unethical practice. Program details can be found in the organization's policy on corporate responsibility.
Operational Variances for State Licensure
The organization's policies and procedures - as well as this program description - identify the minimum operational "baseline requirements" for the clinic. Operational variances to established policies and procedures are authorized by the organization's leadership as a way to meet the conditions and requirements for continued licensure by the state opiate treatment authority and/or other state regulatory agencies. As a general rule, the stricter of any conflicting standards should guide the organization's staff in its decision-making process. However, all such conflicts should be immediately reported to the Vice-President of Clinical Services for resolution.
Research Projects
Porter-Starke Services Opiate Treatment Program specifically prohibits research projects involving patients at the clinic unless this research is voluntary and in the best interest of furthering research in the area of methadone treatment. A prohibition extends to the use of two-way mirrors, cameras for patient monitoring purposes except for security purposes, recording devices or any other technology that could be used to monitor patients and therefore, pose the potential for a violation of patient confidentiality.
Emergency Services
A physician is available for medical consultation 24 hours a day, 7 days a week. The PSS Emergency Services staff uses a pager system to provide emergency services for all enrolled patients. Emergency services staff is briefed on their responsibility to expeditiously handle these calls. In the event any patient legitimately requires crisis intervention services, the staff will make every reasonable effort to assist the patient in accessing those services.
DISASTER PLAN
POLICY: To provide methadone treatment in the event of a disaster.
PURPOSE: Porter- Starke Services, Inc. Opiate Treatment Program (OTP) will be available to serve clients in the event that there is a disaster. A disaster is defined as an instance where human life is unexpectedly threatened or taken by another human, natural disaster, or accident. A disaster is defined as a situation affecting numerous victims either directly or indirectly.
ACTIVATION OF MENTAL HEALTH RESPONSE TEAM (MHRT):
1. Once an organizational disaster is identified:
The Emergency Services Department (ES) will gather event information including the organization’s contact person’s (OCP) name and phone number.
The ES staff member will then contact the Director of ES or a senior clinical/administrative staff member.
The Director or a senior clinical/administrative staff member will contact the OCP to discuss the disaster, discuss the scope of services to be provided, and notify Executive Team members.
The Director of the OTP will be notified.
All PSS Clinical Directors will be notified about the current disaster.
The OTP Director will inform their staff about the disaster and will be available for inclusion on the Team.
ORGANIZATION OF MHRT:
1. The Team will consist of:
MHRT Coordinator: a senior staff member who is trained in Critical Incident Stress Management (CISM).
Additional clinical staff trained in CISM.
Additional clinical staff to assist the CISM staff.
2. The number of staff who will provide services will be dependent upon CISM protocol.
MHRT COORDINATOR RESPONSIBILITIES:
1. Assemble the Team with sufficient staff to address the victims.
2. Will make arrangements with the OCP in a timely manner regarding when, where, and who will be providing services.
3. Brief an Executive Team member of the disaster situation.
4. Approve all clinical handouts.
5. Coordinate and offer follow-up care arrangements with PSS.
PROVISIONS OF METHADONE DISPENSING FOR A DISASTER:
1. Methadone will continue to be dispensed. If the building where the medication is stored is inaccessible and the medication cannot be reached, the nearest methadone program will be contacted for guest dosing.
2. The OTP Program Director will phone/fax the receiving OTP and inform them of the Disaster and coordinate dosing for the clients.
PROVISIONS OF ON-SITE SERVICES FOR A DISASTER:
1. The Team will report to the OCP for updated disaster information and to discuss the emotional status of the attendees.
2. The Team will secure a meeting place and a communication line will be established to a PSS contact person for outgoing and incoming calls.
3. Anyone indicating suicidal or homicidal ideation will be immediately referred to the PSS ES Department or nearest emergency room.
4. Services will be provided utilizing the techniques of CISM.
5. The Coordinator will work with the organization staff to create and distribute clinical handouts pertinent to the community disaster.
6. The Team will communicate any significant clinical concerns to the Coordinator to assess the numbers of affected persons needing further services.
7. The Team members will meet with the Coordinator prior to leaving the scene to debrief or to make arrangements for a debriefing.
8. The Coordinator will contact the local CISM team through the Porter County Sheriff’s Department dispatcher for affected first responders, if applicable.
9. The OTP Director will discuss any clinical concerns with the OCP and discuss available follow-up service options.
PROVISION OF SERVICES AFTER A DISASTER:
1. PSS will offer OTP services to the individuals affected by the disaster.
2. The Executive Team will communicate any fee waivers or reductions to the OTP Director.
COMMUNICATIONS:
1. Communications with the media will be conducted by an Executive Team member or appointee.
2. Event information will be distributed to OTP clinical staff in regards to nature of the event, numbers affected, and possible increase in referrals for services.
3. Front desk staff, After Hours Answering Service, Executive Team, and Admissions staff will be notified of what services are being offered and who will be providing follow-up treatment.
PATIENT ADVISORY COMMITTEE
POLICY:
Porter-Starke Services Opiate Treatment Program is committed to seek and utilize information from patients as a way to assess and improve clinic operations. Therefore, it is the policy of the organization to form and support a Patient Advisory Committee comprised of a cross section of the patient population. This is to serve as a conduit to the Program Director in relaying or presenting patient concerns.
PURPOSE:
To establish the official policy of Porter-Starke Services Opiate Treatment Program on Patient Advisory Committees (PAC) and to assign responsibility for implementation of this policy.
PROCEDURE:
The PAC is primarily a Program Director's tool for addressing patient satisfaction, the Program Director is obligated to exercise leadership and direction on forming, sustaining and nurturing the Patient Advisory Committee.
The committee should be encouraged to meet on a regular basis in the center during open hours but without staff member attendance at the meeting. Actual meeting times and frequency should be left to that committee and facility Program Director to determine. The committee itself is not a Program Director's tool; rather, the comments received from the Patient Advisory Committee are the Program Director's tool. The Program Director must be their initial point of contact. The Program Director must consult with the Vice-President of Clinical Services concerning Patient Advisory Committee suggestions or complaints.
The Program Director is obligated to support and encourage the Patient Advisory Committee to provide feedback to the program from the patient population. He/she is also obligated to honor, to the maximum extent possible, suggestions and comments received from the Patient Advisory Committee, and should be alert for signs that staff members may not be applying sufficient attention to patient relations.
The Patient Advisory Committee may not intrude into management of the center, and it will continue to be the case that many issues
will fall within regulatory constraints or mandates, which may or may not be altered. Nonetheless, the purpose for the formation of the Patient Advisory Committee is to enable the director to make the center as user-friendly as possible, focusing on patients as consumers and customers.
The Patient Advisory Committee should preferably forward their suggestions or complaints and comments to the Program Director in writing, but not necessarily in formal typed fashion. Verbal comments may be also be received. Handwritten submissions are sufficient, and the Program Director is also obligated to respond to the Patient Advisory Committee in writing as soon as possible, and send a copy to the Vice-President of Clinical Services. Individual members of the Patient Advisory Committee may act independently in presenting concerns verbally or in writing.
No attempt may be made by any staff member, including the Program Director, to influence or affect the Patient Advisory Committee; nor may PAC members be compensated in any way for their services. The spirit and intent of the Patient Advisory Committee must be to provide a voice for the patient population absolutely without any fears of retribution.
Beyond these basic guidelines the Patient Advisory Committee must be permitted to function in its own desired fashion.
PATIENT INSTRUCTIONS FOR METHADONE INDUCTION
POLICY:
It is the policy of PSS OTP to ensure that patients being admitted to treatment are afforded full and accurate information regarding all phases of treatment with methadone. The PSS OTP considers the patient admission and induction process to be of such importance as to provide verbal and written instruction, and explanations. It is the responsibility of the admitting staff to provide the documentation, and the admitting physician to ensure that the patient is in receipt of the materials, before proceeding with Medical Evaluation and Physical Examination.
PURPOSE:
To establish the official policy of Porter-Starke Services Opiate Treatment Program on providing essential information regarding the Methadone Induction process to all new patients and to assign responsibility for implementation of that policy.
PROCEDURE:
PSS OTP has developed an instructional document entitled "ABOUT METHADONE AND BUPRENORPHINE.” That is available as part of new patient admission forms. Additional copies are to be made available as handouts for patients, friends, and families.
The instruction booklet covers topics including induction, the basics of methadone, steady-state pharmacology, and important guidelines for patients and significant others. Patients will learn the distinctions between short and long acting opioid drugs (heroin and methadone).
The patient record will contain documentation that this procedure has been accomplished with appropriate dates and signatures.
PATIENT FEE STRUCTURE
POLICY:
Porter-Starke Services Opiate Treatment Program operates primarily as a private treatment program. As such, patients are personally responsible for their own treatment fees and are expected to be accountable for timely payment of all fees.
PURPOSE:
To establish the official policy of Porter-Starke Services Opiate Treatment Program on pricing structure for patient services and to assign responsibility for implementation of that policy.
PROCEDURE:
1. Patient fees include:
a. an admission fee that covers services for the first day
of treatment, medication and lab expense;
b. a $13 daily fee for medication/dosing;
c. a drug screen/urine testing fee, as applicable;
d. additional laboratory fees, as applicable and if
required;
e. PSS OTP reserves the right to impose an additional
fee for guest dosing due to the increased
administrative effort required to document the dose,
process the guest patient, etc.; and
f. PSS OTP reserves the right to impose additional fees
as may be necessary and without advanced
notification.
2. In legitimate emergency situations, credit will be extended to
patients to cover one day's fees only. When a patient becomes unable to pay for services, a medically-supervised withdrawal may be instituted.
3. The center does not charge patients for non-attendance.
4. Any fees paid in advance by patients electing to leave
treatment will be refunded. To refund patient's fees, the Program Director will forward a request for check with the patient's name, mailing address and payment record to the Accounting Department for approval. The accounting department will issue a refund check.
GUEST DOSING
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program to accept patients from other centers as guest dosers. Requests for guest dosing can normally be accommodated with 72 hours advance notice. In the case of a request received with less than 72 hours advanced notice, guest dosing status may be offered at the discretion of the Program Director. The duration of guest dosing will be limited to 30 days per request.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on guest dosing, provide guidelines for accommodating guest dosers and assign responsibility for implementation of the policy.
PROCEDURE:
The center requires a guest dose request from the sending program and on the program's letterhead that contains the following information:
1. The patient's temporary address or residence;
2. A telephone number where the patient can be reached during the time that the patient is guest dosing;
3. The exact length of stay requested;
4. A specification of medicating instructions by the sending center, i.e., exact dose in milligrams;
5. A specification of precise orders regarding take-home doses authorized by the sending program;
6. A specification of precise travel take-home doses for the patient to return home;
7. The signature of the sending program's Medical Director;
8. An accurate physical description of the patient, to include scars, tattoos, of their patient. A picture identification is preferred; and
9. The patient will be expected to produce a picture identification issued by a governmental entity;
Upon receiving the request, a Patient Data Record is constructed in the computer. The Patient Data Record must provide the full name and address of the referring clinic and also the contact person at the referring clinic.
In the instance of a center patient requesting or needing guest dosing at another program, the counselor is authorized to contact the receiving program to ascertain their requirements to guest-dose our patient. The counselor shall complete a special request form to guest dose the patient for the Medical Director's signature. He/she is authorized to send the request for guest dosage to the receiving program only if the patient has signed a proper release of information form for that purpose. The patient will provide identification when they arrive for a guest dose.
The program has the right to refuse a guest dose but this is unlikely. Financial arrangements should be communicated to the patient before they come to guest dose. Drug testing if applicable may occur but the payment for the dose and the drug test is the responsibility of the patient. Exclusionary or ineligibility criteria may be may be limited to patients who present for services that are under the influence of a substance and are incoherent or otherwise impaired.
TRANSFER OF PATIENTS TO ANOTHER
METHADONE TREATMENT PROGRAM
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that requests for transfers to other methadone centers will be approved and accommodated with advanced notice.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on the transfer of patients to another methadone treatment center and to assign responsibility for implementation of the policy.
PROCEDURE:
1. The patient must request transfer from his or her counselor. The counselor is expected to ascertain, and document thoroughly, the patient's rationale for desiring to change centers. Patient movement between centers should be discouraged, where possible, but not to the detriment of the patient.
2. Should the patient persist in requesting a transfer, the primary counselor will discuss the matter with the patient to determine if he/she has a preference regarding another provider organization. The counselor then completes a "Consent for Release of Information" Form which enables the center to release dosage and other treatment information to the other provider.
3. The Medical Director, Program Director and other team members acknowledge client’s request for transfer generally in the clinical staff meeting.
4. The counselor establishes contact with the receiving center to ascertain their requirements and availability of treatment space, dosage limitations, or other factors which the patient is reasonably entitled to know.
5. The counselor provides the receiving clinic with a copy of the patient's Consent for Release. The licensed registered nurse may then provide medical information to the receiving clinic.
6. The licensed registered nurse completes the discharge portion of the patient's medical chart. The date of discharge is the last dosing day at the discharging facility.
7. The counselor completes the discharge and documents it in the patient’s record.
8. The Medical Director is presented the discharge summary for review and signature. The file is then closed.
TRANSFER OF PATIENTS FROM ANOTHER FACILITY
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program to accept patients who are transferring to the PSS OTP clinic from other opioid treatment programs. Inherent in this policy is the expectation that complete documentation must be provided as part of the transfer process.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on the transfer of patients from other opioid treatment programs to the clinic operated by Porter-Starke Services Opiate Treatment Program and to assign specific responsibility for implementation with this policy.
PROCEDURE:
The transferring center must provide the following minimum
information:
1. Documentation that the patient meets current diagnostic criteria for Opioid dependence;
2. Copies from the patient's record to reflect the patient’s most current health and physical;
3. Admission date;
4. Original date of admission for current treatment episode;
5. Current phase and date in phase;
6. Urine drug screen results for past year;
7. Dose level (to be confirmed by nursing staff at the transferring center)
8. Most recent TB test results and the date of that test;
9. Reason for transfer; and
10. Other information as specified on release of information.
Patients transferring in may not be accepted for treatment unless the sending center provides telephone confirmation and written transfer documentation.
TAKE-HOME PRIVILEGES and SPECIAL TAKE HOME DOSES
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that a patient may be given a take home and/or a special take-home dose(s) of methadone, when, in the clinical judgment of the Medical Director and Program Director, the patient is found to be responsible in the handling of methadone. If requesting a special take-home a verifiable hardship can be proven.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on take home privileges and special take-home doses, and to assign specific responsibility for implementation of this policy.
PROCEDURE:
Appropriate staff, such as the counselor’s, the Program Director, or the registered nurse, may request that a patient receive a take home dose or a special take out. The special request order form is completed and submitted to the program physician for approval. The patient may be granted approval if they: a. Will benefit from obtaining unsupervised doses and, b. Has demonstrated responsibility in taking opioid treatment medication as prescribed.
Because of exceptional circumstances such as illness, personal or family crises, travel, or other hardship, a patient who is unable to conform to the applicable mandatory schedule may be permitted a temporarily reduced schedule for dosing in the Center, provided the patient is also found to be responsible in handling methadone. The rationale for a temporary exception to a mandatory schedule is to be based upon the reasonable clinical judgment of the Medical Director with input and concurrence of the Program Director. For clarification, the Medical Director will ultimately be responsible for determining the number of special take-home doses.
The center's "Special Request Order" is utilized to record the rationale adopted for any such patient request and provides the location for the Medical Director's signature, dating and credentialing.
Any patient requesting a take home dose or special take-home dose(s) of methadone shall initially make his/her request to the
counselor. The counselor shall:
1. Ascertain the exact reason for the patient's request;
2. Ascertain whether the stated reason is for a Phase change or is clearly a crisis or hardship as delineated above;
3. If it is a hardship, obtain from the patient legitimate written verification in advance, that is legitimate, verifiable, which clearly supports the patient's request;
4. The counselor prepares the "Custom Order Form" which is presented to the Program Director and Medical Director for approval and signature.
5. Following the Medical Director's approval, the Physician may be required to submit the patient's request to the State licensing/regulatory authority and CSAT for final authorization if they are allowing a patient special take-home privileges. This may or may not need approval from the Indiana licensing/regulatory authority or CSAT.
Counselors are personally responsible for the accuracy and truthfulness of the completed request form. They shall sign and credential the request providing the Medical Director with a clear assertion of the facts associated with the request.
PATIENTS ON PROBATION OR PAROLE
AND COURT-ORDERED PATIENTS
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program regarding delivery of services to patients on probation or parole and court ordered patients, and to assign specific responsibility for implementation of the policy.
POLICY:
Porter-Starke Services Opiate Treatment Program recognizes the need of some patients to continue to receive methadone services despite involvement with the criminal justice system. Therefore, it is the policy that Porter-Starke Services Opiate Treatment Program will provide services to patients involved in the criminal justice system when delivery of such services can be provided in a manner consistent with the best medical and clinical practices and all applicable laws, rules or regulations. PSS OTP recognizes that each patient has the option to enter treatment despite criminal justice system consequences. Once accepted into treatment, the center incurs the obligation for reporting the patient's progress to the referring agency. A patient who is receiving treatment at the center as a criminal justice referral retains the same rights extended to any patient receiving treatment. Written consent is revocable only upon the passage of a specified amount of time or the occurrence of a specified, ascertainable event. The time or occurrence upon which the consent becomes revocable may be no later than the final disposition of the conditional release or action in connection with which the consent was given.
PROCEDURE:
The Program Director and clinical staff members are responsible for compliance with this policy.
DRUG ENFORCEMENT ADMINISTRATION
(DEA) RECORD-KEEPING
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that the center will operate in accordance with all United States Drug Enforcement Agency regulations.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on record-keeping as required by the U.S. Drug Enforcement Administration (DEA) and, to assign specific responsibility for implementation of the policy.
PROCEDURE:
The United States Drug Enforcement Administration (DEA) requires that certain records be maintained at the center for production during any DEA audit. While DEA audits are normally scheduled on a two - three year cycle (and also on a surprise visit basis), they nonetheless request that the documents listed herein are maintained and kept current at each center. These documents are to be kept and maintained in a hardback, three-ring binder, which must be routinely stored in the medication safe. The Program Director has the primary responsibility to ensure the information is correct, complete, current and up-to-date. He/she may expect assistance from the center's licensed Registered nurse or the Regional Representative at Roxanne Pharmaceuticals in maintaining these records, but is personally charged with the primary responsibility for their contents.
The following materials required to be maintained in the binder are:
1. A copy of the initial (center opening) methadone inventory which is prominently labeled "Initial Inventory";
2. All biennial inventories, labeled as "Biennial Inventory" signed by pharmacy personnel, including if done at beginning or end of business day;
3. A listing on center letterhead stationary of all licensed center personnel who are permitted to sign for receipt of the methadone (including name, date of birth and social security) with copy provided to Roxanne Pharmaceuticals;
4. A similar listing of all licensed personnel who know the current safe combination (including name, date of birth and social security);
5. A copy of the Power of Attorney Form;
6. A copy of any letter which changes or changed the Biennial Inventory date;
7. A copy of any DEA Form 106 or SAI/DEA Form 41 which has been used for the center;
8. All licenses and permits issued to the program physician, pharmacist and nurses;
9. A copy of the center's annual inventory prominently identified as such per state requirements;
10. A listing of the alarm company which provides the monitoring service for the center which includes telephone numbers for that company;
11. A record of all quarterly alarm system tests that provides the
time, date, testing person, and name of the person at the
alarm company or police department who confirmed the test.
All medical staff members are responsible for conformance with this policy.
BREATH ALCOHOL TESTING FOR PORTER-STARKE SERVICES OPIATE TREATMENT PROGRAM PATIENTS
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program to ensure that patients being treated are monitored and observed in such a manner as to reduce any risk associated with potentially dangerous drug interactions involving methadone and other drugs/substances. The PSS OTP is aware of the extent of mortality associated with alcohol in combination with methadone and other drugs. To minimize these risks, PSS OTP provides a detection device at the clinic to provide instant objective measures of breath alcohol levels.
PURPOSE:
To establish the official policy of Porter-Starke Services Opiate Treatment Program on conducting the analysis of breath alcohol levels on selected Porter-Starke Services Opiate Treatment Program patients and ensure accurate objective analysis of breath alcohol levels as needed.
PROCEDURE:
In the event that alcohol intoxication is suspected (based on general appearance, behavior, speech, gait, etc.), the patient should be taken to a private room where the testing can be accomplished while respecting the privacy of the patient.
A positive test result alone will not result in the refusal to dose a patient; the test serves as only one clinical indicator for the staff to use in making a determination and reaching a decision about patient dosing. The patient has the right to return for re-testing after 1-3 hours.
Depending on the degree of impairment and level of intoxication program staff may consider other steps to ensure the safety of the patient and the public such a preventing a patient from operating a motor vehicle.
Program Directors are responsible for conformance with this policy on a daily basis.
Urine Drug Screening
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that urine drug screens shall be collected on each patient at the time he/she enters treatment and prior to administration of initial dose of methadone. The nursing staff or the intake counselor is responsible for collecting the sample prior to initial medication of the patient. Drug screen urinalysis shall test for opiates, methadone, amphetamines, cocaine, barbiturates, benzodiazepines, alcohol, and THC or as otherwise required by state/federal regulations. Urine drug screen samples, once collected, shall be appropriately labeled, sealed, placed with the lab requisition form. The storage location shall be in an area not accessible to patients.
PURPOSE:
To establish the official policy of the center as it pertains to urine drug screen collection, testing, and recording all the effects of urine drug screens on treatment outcome, and to assign specific responsibility for implementation of the policy.
PROCEDURE:
In the collection of urine samples, the following additional measures - intended to protect the test integrity by minimizing opportunities for falsification and possible contamination - are to be followed. Patients should always be treated with dignity and respect during screening procedures. All screens will be individualized to the patient and observed by a staff person:
1. An unannounced urine drug screen is normally collected at least eight (8) times per year from each patient, but may occur more frequently at staff discretion. The sample is collected and used as a therapeutic deterrent and as a diagnostic tool. The sample collection and sample results are documented in the patient chart, along with any confrontative or remedial measures applied.
2. Purses, jackets or heavy clothing are not permitted in the rest room with the patient. Staff members should be alert for any attempts to contaminate or adulterate the urine sample.
3. Where a same-sex staff member is not available to observe collection of the sample, an entry in the patient's record will
be made to document that the urine collection was not monitored.
4. Refusal to produce a urine sample on demand is to be considered a positive urinalysis. An inability to void requires staff members to be sensitive to the fact that not every
patient will be able to produce a sample on demand every time. Therefore, should a patient state he or she is unable to void, that patient is to be instructed that a urine sample must be provided on the very next center visit, and that any claimed inability to void at that time will not be accepted. The patient is to be informed that dosing may be delayed until a sample is provided and that any take-home privileges the patient may have earned may be withheld pending sample submission.
5. A cold bottle of urine handed in by a patient, or a sample which contains any foreign substance, in response to a demand for a urine sample, is to be considered a positive urinalysis.
6. Chain of custody will be ensured by correct labeling and shipping of the urine sample immediately open collection. The identification labels for each sample will be duly noted in the urine collection log.
7. Urinanalysis reports/results will be distributed to the nursing and counseling staff. The nursing staff or the Medical Director will interpret the results of the drug screen.
8. Urinanalysis results will be reviewed by the clinic staff to determine if there is remedial action that is needed such as scheduling the patient with the Medical Director.
Urine Drug Screening II
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that urine drug screens shall be collected on each patient. The counselor is responsible for collecting the sample. Drug screen urinalysis shall test for opiates, benzodiazepines, barbiturates, cocaine, marijuana, methadone (and its metabolites), amphetamines and alcohol and or as otherwise required by state/federal regulations.
Benzodiazepines such as diazepam (Valium) and clonazepam (Klonopin) will be closely monitored to thoroughly explore patient use of benzodiazepines at admission and on a regular basis if indicated.
PURPOSE:
To establish the official policy of the center as it pertains to benzodiazepine use.
High dose benzodiazepines can cause serious problems, including severe intoxication and higher risk of injuries and fatal overdoses. These risks are potentiated when high doses of benzodiazepines are mixed with methadone or other drugs that produce sedation and respiratory depression, even among patients who have developed tolerance for the respiratory-depressant effects of opioids.
PROCEDURE:
In the collection of urine samples, the following measures are to be followed:
1. An unannounced urine drug screen is normally collected at least eight (8) times per year from each patient, but may occur more frequently at staff discretion. The sample is collected and used as a therapeutic deterrent and as a diagnostic tool.
2. If the UDS is positive for benzodiazepines, ascertain the source: is the drug a bona-fide prescription or an illicit use or abuse. The patient shall be required to produce, within seven days, the prescription or the prescription bottle in resolving any question. Staff members are expected to check with the Medical Director regarding the legitimacy of the claimed prescription. Full and thorough documentation
is required in the patient's chart.
a. Inform the patient that use of benzodiazepines negatively affects attendance at treatment sessions and progress in methadone treatment. And, that regular benzodiazepine use for 3 months or more may be associated with physiologic dependence, even when taken in prescribed doses. Further inform the patient that benzodiazepine use can be linked to injury and fatal overdose
b. Obtain a signed consent form from the patient to call
the prescribing physician for verification of any medication prescribed by the physician as a condition of health care being provided. A follow-up letter, along with letter of release shall then be sent to the prescribing physician. All verification by telephone and letter must be documented in the progress notes along with the outcome. This procedure must be performed on a monthly basis if the claimed prescription continues.
c. Upon producing the prescription, the counselor shall
mail the required form letter to the prescribing physician, notifying him or her of the patient's methadone status and requesting that physician's determination whether the patient is to be continued on the medication as a condition of the health care being provided.
d. If the patient cannot produce a bona-fide prescription
within the seven day period, or admits that the substance detected was an illicit drug use, the counselor shall treat the issue as a positive urine drug screen. Counselors are expected to be fair to the patient. In instances where the patient continues to deny use, or claims a lab error, the counselor is authorized to place the patient on probation until the next random urine drug screen, at which time a negative drug screen may excuse the patient from further process. However a repeat positive urine drug screen for the drug at question will then serve to trigger all other program responses.
3. If the patient cannot cite a bona-fide prescription, or admits to illicit drug use, or if the prescription is for a non-prescription drug, i.e., benzodiazepine, the counselor shall:
a. Document a session with the patient wherein
the patient is made aware that a second positive urine drug screen may result in an appropriate loss of take-home privileges.
b. If the urine drug screen in question is a second
positive urine drug screen reflecting illicit drug use, the counselor may recommend removing take-home privileges for a period of time to the physician by down-phasing the patient (one phase at a time or as otherwise required by state law) to a phase deemed sufficient to convince the patient his or her illicit drug use will not be condoned by the continuance of take-home privileges. Take-home privileges may be restored in similar fashion with the provision of a clean urine drug screen, and or as otherwise required by state standards, at the patient's expense, to prove drug-free status.
c. In conjunction with the action required in
paragraph 3. b. above, the counselor may elect
to intensify treatment intervention. Probationary periods, formal warning letters, or treatment contracts may also be utilized. Any treatment course or option selected must be entered into the patient's treatment plan and must be satisfied prior to any restoration of privileges by up-phasing.
d. Cases which require the actions in
paragraph. 3. a. and b., above must be discussed with the Program Director.
POSITIVE DRUG SCREEN RESULTS
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that urine drug screen results are considered to be presumptive. Any urine drug screen indicating a positive result will require a documented counselor interaction.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on positive drug screen results and to assign responsibility for implementation of the policy.
PROCEDURE:
1. Ascertain the source of the substance in question, i.e., is the drug a bona-fide prescription or an illicit use or abuse. The patient shall be required to produce, within seven days, the prescription or the prescription bottle in resolving any question. Staff members are expected to check with the Medical Director regarding the legitimacy of the claimed prescription. Full and thorough documentation is required in the patient's chart.
2. If the patient reports that the urine drug screen in question is the result of a prescription medication, the counselor shall:
a. Obtain a signed consent form from the patient to call
the prescribing physician for verification of any medication prescribed by the physician as a condition of health care being provided. A follow-up letter, along with letter of release shall then be sent to the prescribing physician. All verification by telephone and letter must be documented in the progress notes along with the outcome. This procedure must be performed on a semiannual basis if the claimed prescription continues.
b. Upon producing the prescription, the counselor shall
mail the required form letter to the prescribing physician, notifying him or her of the patient's methadone status and requesting that physician's determination whether the patient is to be continued on the medication as a condition of the health care being provided.
c. If the patient cannot produce a bona-fide prescription
within the seven day period, or admits that the substance detected was an illicit drug use, the counselor shall treat the issue as a positive urine drug screen. Counselors are expected to be fair to the patient. In instances where the patient continues to deny use, or claims a lab error, the counselor is authorized to place the patient on probation until the next random urine drug screen, at which time a negative drug screen may excuse the patient from further process. However a repeat positive urine drug screen for the drug at question will then serve to trigger all other program responses.
3. If the patient cannot cite a bona-fide prescription, or admits to illicit drug use, or if the prescription is for a non-prescribable drug, i.e., cocaine, the counselor shall:
a. Document a session with the patient wherein
the patient is made aware that a second positive urine drug screen may result in an appropriate loss of take-home privileges.
b. If the urine drug screen in question is a second
positive urine drug screen reflecting illicit drug use, the counselor may recommend removing take-home privileges for a period of time to the physician by down-phasing the patient (one phase at a time or as otherwise required by state law) to a phase deemed sufficient to convince the patient his or her illicit drug use will not be condoned by the continuance of take-home privileges. Take-home privileges may be restored in similar fashion with the provision of a clean urine drug screen, and or as otherwise required by state standards, at the patient's expense, to prove drug-free status.
c. In conjunction with the action required in
paragraph 3. b. above, the counselor may elect
to intensify treatment intervention. Formal warning letters, or treatment contracts may also be utilized. Any treatment course or option selected must be entered into the patient's treatment plan and must be satisfied prior to any restoration of privileges by up-phasing.
d. Cases which require the actions in
paragraph. 3. a. and b., above must be
discussed with the Program Director.
4. Patients who test positive for opiate use through urinalysis should be encouraged to voluntarily raise their daily dose, to eliminate any narcotic cravings they may be experiencing.
5. Patients receiving take-home medication, who produce a positive urinalysis or one negative for methadone, may be placed on probation for 90 days and will receive more frequent urine drug screens during that probation period. A second positive urine drug screen during that period may result in patient's loss of take-home privileges.
6. Any termination or restoration of take-home privileges does require the Medical Director's approval. Staff members should be prepared to brief the Medical Director and explain their rationale behind their recommended actions.
7. The Medical Director is expected to exercise reasonable clinical judgment as a way to ensure that the organization complies with state and federal rules pertaining to the interpretation and use of positive drug screen results. Toward that end, the clinical staff (nurses and counselors) will ensure that the Medical Director is provided with all pertinent information about the patient so that the most appropriate clinical decision can be made.
TREATMENT RETENTION OF PATIENTS
WITH CONTINUOUS POSITIVE DRUG SCREENS
POLICY:
Porter-Starke Services Opiate Treatment Program recognizes that some patients may continue to use illicit drugs during treatment and, that such use will be detected through urine drug screenings. In such cases, it is the policy of Porter-Starke Services Opiate Treatment Program to use clinically-appropriate interventions in an attempt to motivate the patient to discontinue drug use.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on the retention of patients who continuously have positive urine drug screens.
PROCEDURE:
Appropriate counselor intervention begins with informing the patient of urinalysis results. Patients who test positive for Opiate use through urinalysis should be encouraged to voluntarily raise their daily dose to eliminate any narcotic cravings they may be experiencing. The counselor shall:
1. Identify the chemical being used, the route of administration, and the frequency of use;
2. Counselor should consider each of the following for implementation in the individual case:
a. Withhold take-home privileges until urinalyses are
free of illicit drugs;
b. Place patient on 90-day probation or rescind take-
home privileges by reduction in Phase;
c. Document in the patient's chart, if appropriate, the
patient's written rationale for continuing treatment;
d. Increase counseling contacts;
e. Refer to outside agency such as Narcotics
Anonymous, Alcoholics Anonymous, Cocaine
Anonymous, Community Mental Health Center, personal physician, religious advisor, etc.
Documentation is required from referral agency to
ensure patient has been responsible in accepting
treatment from that agency;
f. Effect counselor change;
g. Transfer to inpatient, intensive outpatient, or another
outpatient treatment center;
h. Increase frequency of urine drug screens;
i. Consider involuntary medically supervised withdrawal;
and
j. Creativity and imagination are key in developing
potential strategies.
3. Staff patients with the treatment team. Staffing is mandatory
of positive urinalysis for illicit drugs. Staffing shall occur as
deemed appropriate. Staffing should attempt to identify
newer alternative approaches. If no intervention is
successful, a second staffing is mandatory. Center policy is
to utilize all appropriate interventions.
4. Submit the case, following staffing, to the Program Director for his/her opinion(s) relative to treatment direction, treatment successes to date, treatment successes in the future, and humanitarian concerns surrounding the patient's treatment.
5. The Program Director shall then submit all these known factors and subjective opinions to the Medical Director for final decision.
6. Once the Medical Director's determination is issued, treatment shall either proceed toward discharge or continuation of treatment per team direction.
MEDICALLY SUPERVISED WITHDRAWAL
POLICY:
Porter-Starke Services Opiate Treatment Program recognizes the right of every patient to request and receive medically supervised withdrawal (MSW) services. Therefore, it is the policy of Porter-Starke Services Opiate Treatment Program that clinic staff will assist every patient who requests medically supervised withdrawal.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on medically supervised withdrawal and to assign responsibility for implementation of the policy.
PROCEDURE:
The Medical Director retains sole authority to order medically supervised withdrawal protocol. When a patient requests a medically supervised withdrawal, the counselor shall:
Thoroughly explore with the patient the rationale for the
withdrawal request, ensuring the patient's request is not the result of dissatisfaction with the program rules, regulations, or counselor approach;
2 Discuss the request with the treatment team;
3. Explain the withdrawal process with the introduction of
standard dose levels and the range of numbers of days spent at each dose level.
Develop, in conjunction with the patient, a workable
withdrawal plan which may include twelve step support attendance verification;
5. Meet with the patient to cooperatively determine a viable aftercare plan that includes all the patient's spiritual, emotional, physical, and recreational needs. The counselor should attempt to obtain and document a commitment from the patient as possible;
6. Complete the center's Titrate/Detox form, reflecting the desired rate of withdrawal, expressed as the number of days at each dose level. The standard options are to be explained including that the physician can withhold one or more options if deemed appropriate;
7. Submit the request to the Medical Director via the Program Director;
8. Develop a supportive, individualized MSW plan including frequency of counseling sessions;
9. Maintains close counseling oversight, providing as much support and encouragement as possible during the withdrawal effort;
10. Documents, the degree of motivation and effort exhibited by the patient to connect with or bond with a twelve step support;
11. Ensure that the patient is fully informed of the conditions of resumption of maintenance treatment either during or following MSW;
12. Complete the discharge paperwork;
13. Submit the patient's record to the Program Director for review.
The medication reduction schedule also proceeds according to dose levels.
Medically Supervised Withdrawal Against
Medical Advice (AMA)
It occasionally occurs that a patient will request a medically supervised withdrawal schedule which is clearly self-defeating. Patients may be totally unprepared, responding to external pressures, seeking unrealistic MSW schedules, and and/other factors contributing to an extremely poor prognosis.
The Program Director is expected to review each and every medically supervised withdrawal schedule before it is presented to the Medical Director. When MSW is requested despite serious contraindications, an initial schedule will be requested.. When the schedule selected is clearly one that is not in the patient's best interests, the Medical Director must:
1. Meet with the counselor and patient and advise both why the schedule selected is inappropriate;
2. Discuss with the counselor and patient a schedule which is appropriate. The counselor must then:
Record, in the patient's chart, the results of this
discussion including the recommendations and advice
given the patient;
Obtain, from the Medical Director, his/her withdrawal
orders following the meeting between patient and
Medical Director.
Ensure, if at all possible, that the Medical Director's orders have not restricted standard MSW options and, at a minimum, provide for a "hold" provision in the schedule.
Should the patient continue to insist on a withdrawal schedule which is contrary to the advice and guidance provided the patient by the above actions, the Program Director is obligated to permit the patient to commence the withdrawal even if AMA - he/she may not delay, defer or deny the patient this basic right.
A full and thorough documentation of the advice given the patient, plus the patient's expressed wishes AMA, must be entered into the patient's progress notes.
Resumption of Opiate Use During Medically
Supervised Withdrawal
MSW, whether a medically indicated and appropriate procedure or AMA, it is a voluntary procedure. As such the action to discontinue MSW, resume MMT, or adjust the MSW schedule is also voluntary. It is not uncommon for patients who are involved in a methadone dose taper (MSW) to experience a return of drug craving, etc., associated with a resumption of opiate use or being at risk of resumption of opiate use. A “safety net” is provided MSW patients in the form of options. Without delay, the patient in relapse or at risk of relapse can "hold" the dose thereby preventing further dose reductions and/or increase dose 1 or 2 standard methadone levels to reduce craving, etc. In some cases this action, on the part of the patient, is adequate to re-stabilize, without further action or intervention needed. Increased support and supervision with documentation are provided by the counselor as a minimum.
The counselor must document the events and arrange consultation with the treatment team and the physician. After consultation with the physician, the following actions may be taken:
1. Cancel MSW with resumption of MMT with appropriate dose adjustments to ensure an adequate dose;
2. Continue MSW with temporary increase to restabilize, then resume schedule at a slower rate of withdrawal; and
3. Refer to alternate modality such as inpatient treatment.
The counselor must document a counseling session/therapeutic intervention to address the circumstances leading to the return to narcotic drug use and the actions taken.
SHORT-TERM DETOXIFICATION TREATMENT
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that short-term detoxification (30 days or less) can be provided for patients based on their physiological and psychological needs and as determined/ordered by the Medical Director.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on short-term detoxification and to assign responsibility for implementation of the policy.
PROCEDURE:
1. Methadone must be administered daily under close observation.
2. Take-home medication is not allowed during short-term detoxification.
3. A history of 1 year physiological dependence is not required for admission to short-term detoxification.
4. Patients who have been determined by the Medical Director to be currently physiologically narcotic dependent may be placed in short-term detoxification treatment.
5. Each patient admitted for short-term outpatient detoxification shall be required to submit a urine drug screen at admission and weekly thereafter.
6. The 30-day initial treatment plan is required as well as an after care plan. A periodic treatment plan evaluation required for comprehensive maintenance patients is not required for short-term detoxification patients. However, a primary counselor must be assigned to monitor a patient's progress toward the goal of short-term detoxification and possible drug-free treatment referral.
7. A patient is required to wait at least 7 days between concluding a short-term detoxification treatment episode and beginning another. Before a short-term detoxification attempt is repeated, the Medical Director shall document in the patient's medical record that the patient continues to be, or is again, physiologically dependent on narcotic drugs. The Medical Director may decide to place a patient on long-term detox after a failed attempt of short-term detox or may place patient on long-term detox rather than a short-term detox on admission.
8. Each patient shall participate in counseling on a weekly basis or as otherwise required by the state regulatory or licensing authority.
LONG-TERM DETOXIFICATION TREATMENT
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that long-term detoxification (more than 30 days) can be provided for patients based on their physiological and psychological needs and as determined/ordered by the Medical Director. For purposes of this policy, long-term detoxification is defined as "over 31 days but not to exceed 180 days" or as defined by state requirements and regulations.
PURPOSE:
To establish the official position of Porter-Starke Services Opiate Treatment Program on long-term detoxification and to assign responsibility for implementation of the policy.
PROCEDURE:
1. In the event that an established maintenance patient elects to undergo long-term detoxification, the organization’s criteria for take-home medications (described elsewhere in this manual) will apply; the Medical Director will determine the most appropriate dosing schedule for such patients;
2. A history of one (1) year opioid addiction is not required for admission to long-term detoxification;
3. The Medical Director shall document in the patient's record that short-term detoxification is not of sufficient length to meet the patients treatment goals. The Medical Director shall then document this information in the patient's medical record before long-term detoxification may begin. The Medical Director shall sign and date these entries;
4. An initial drug screening test is required for each patient. At least one additional random test must be performed monthly on each patient during long-term detoxification;
5. The initial treatment plan and periodic treatment plan evaluation required for comprehensive maintenance patients are also required for long-term detoxification patients, except that the required periodic treatment plan evaluation is required to occur monthly;
6. Each patient shall participate in counseling on a weekly basis;
7. A patient is required to wait at least 7 days between concluding a long-term treatment episode and beginning another. Prior to a long-term detoxification attempt being repeated, the Medical Director shall document in the
patient's record that the patient continues to be or is again physiologically dependent on narcotic drugs;
Detoxification Services
The clinic does not routinely provide detoxification services. In the event that any patient requires detoxification services, the following guidelines will apply and will govern the administration and provision of detoxification services. These guidelines have the full effect of organizational policy and are in addition to those provided elsewhere in this Core Program Description and the organization's Policy and Procedures Manual:
1. Admission criteria: Patients admitted for detoxification services must meet the organization's general admission criteria as described in the organization's Opioid Treatment Program Description and, meet the diagnostic criteria for withdrawal as specified in the American Psychiatric Association's Diagnostic and Statistical Manual (current edition). Admission priority will be given to women who are pregnant.
2. A physical examination or evaluation will be conducted by the Program Physician and fully documented on each patient who is considered for detoxification services.
3. In the event that patients receiving detoxification services require treatment for other, co-existing health issues, the Program Director and treatment staff will ensure that appropriate referrals are made for mental health services, substance abuse treatment, pregnancy, prenatal care (where appropriate), and infectious diseases (including but not limited to HIV, hepatitis and other sexually transmitted diseases).
4. In the event that a detoxification patient is incarcerated nursing or counselor staff will notify the medical staff at the jail. DEA regulation prohibits methadone dosing at the jail
5. All detoxification (and/or medically supervised withdrawal) services will be directly monitored and supervised with the Medical Director.
6. For patients involved in detoxification for fourteen (14) days or less, the program offers a minimum of four counseling sessions per week. For patients enrolled in detoxification (and/or medically supervised withdrawal) services for six months or less, each patient will receive a minimum of two counseling sessions per week for the first month and a minimum of two counseling sessions each month thereafter. Appropriate documentation will be maintained in each patient record to document the counseling sessions.
7. The medical and physiological impact of detoxification (including medically supervised withdrawal) will be explained to each person who is admitted for detoxification services. This verbal explanation will be provided as part of initial patient orientation and will include a discussion of the impact of detoxification - including accelerated withdrawal - and a focus, if appropriate, on the effects on persons with co-occurring mental disorders and physical health problems, needs and conditions;
PATIENT DISCHARGE
POLICY:
It is the policy of Porter-Starke Services Opiate Treatment Program that patient discharges will be planned and conducted through the application of established procedures as outlined below.
PURPOSE:
To establish the official policy of Porter-Starke Services Opiate Treatment Program on the discharge of patients and to assign responsibility for implementation of that policy.
PROCEDURE:
The following procedures will be followed:
Voluntary Discharge
The following steps govern the voluntary discharge process:
1. Patient meets with counselor to complete the required forms;
2. Counselor presents his/her recommendations to the Program Director for approval;
3. Medical Director issues his medically supervised withdrawal protocol and any supplementary instructions;
4. Counselor meets with patient to formulate after-care plan, to include selection of support system(s);
5. Counselor provides encouragement and on-going support;
6. Nurse decreases daily dosage as ordered by the Medical Director and evaluates the patient on a daily basis;
7. Counselor and nurse report the case at weekly staffing;
8. Following medically supervised withdrawal and discharge, counselor closes out the patient's record with supporting documentation;
9. Program Director reviews chart for quality and quantity of discharge paperwork.
Involuntary Discharge
There will be occasions when patients may be terminated from treatment. Patients, who fall into this category, are those who frequently and persistently abuse opioids or other drugs, who become chronic abusers of alcohol, who become or continue to be actively involved in criminal behavior, who perform verbal or physical abuse directed at staff or other patients, or who
persistently fail to adhere to the requirements of the treatment program.
Any patient who attempts to sell, deliver, or otherwise dispose of the prescribed methadone by any illicit means should be withdrawn from the methadone as quickly as is medically safe and referred to other treatment sources as may be clinically indicated.
Notwithstanding the requirement for therapeutic confrontation, counselors are not expected to tolerate repeated verbal abuse or physical abuse in any form or frequency. Counselors are expected to thoroughly document instances of patient misbehavior, as delineated above, and make every effort to lead the patient to self-correction.
The following steps pertain to the involuntary discharge process:
1. Counselors will meet with Program Director to review all prior efforts on the patient's behalf and to explore alternative options.
2. Should involuntary discharge be warranted, the Program Director makes recommendation to the Medical Director.
4. Should involuntary discharge be warranted, the Medical Director will issue his determinations and subsequent medically supervised withdrawal protocol.
5. Counselor meets with patient and informs the patient of action selected. Patient may receive assistance, if he or she so desires, with transfer assistance to another center in lieu of a medically supervised withdrawal procedure at the center.
6. Counselor closes out case as a transfer (as applicable) or, the nurse begins medically supervised withdrawal protocol.
7. Counselor closes out patient record following medically supervised withdrawal.
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