Section 440IAC4.4-2-4.5. Uniform criteria for programs that are certified as outpatient under section 4 of this rule

  5. (a) Each outpatient certified program shall provide at least outpatient treatment services and may provide intensive outpatient treatment services to those individuals whose assessments indicate a need for these services.

  (b) If an outpatient certified program has or holds itself out as having intensive outpatient treatment services, it shall meet the requirements at 440 IAC 4.4-1-1(12).

  (c) Each program shall have specific minimum admission criteria, including the following:

(1) The consumer has a documented history of current excessive use of alcohol or other drugs.

(2) The individual is experiencing significant functional impairments in one (1) or more of the following areas:

(A) Activities of daily living.

(B) Interpersonal functioning.

(C) Psychological functioning.

(D) Ability to live without recurrent abuse of chemicals.

(3) The program shall consider whether the consumer has adequate support systems to foster recovery.

(4) There are no presenting medical or unstable psychiatric conditions that would preclude the consumer's participation in this level of treatment.

(5) A more intensive level of treatment is not indicated from the intake and assessment.

  (d) The program shall have a written policy and procedure for conducting consumer intake assessments meeting the following criteria:

(1) The consumer intake assessment shall take place within two (2) weeks of the consumer's first contact with the agency.

(2) The intake assessment shall include, but not be limited to, the following items of information:

(A) A psychosocial history.

(B) Emotional and behavioral functioning.

(C) Alcohol and other drug use history.

(D) Medical conditions.

(3) The individual shall be screened for co-occurring disorders.

  (e) The program shall refer the individual to appropriate treatment, or link with another program with special expertise if:

(1) there are medical or unstable psychiatric conditions that would preclude the consumer's participation in this level of treatment; or

(2) a more intensive level of treatment is indicated from the assessment.

  (f) The program shall have written policies and procedures for the development of a treatment plan, which includes, at a minimum, the following:

(1) Each consumer shall have an individualized treatment plan.

(2) Each consumer shall have the opportunity to participate in developing the treatment plan.

(3) The comprehensive treatment plan shall be completed by the third session.

(4) Each treatment plan shall be reviewed as appropriate with the consumer, but at least every sixty (60) calendar days, and revised as necessary.

(5) The review of the treatment plan shall address the attainment of treatment goals.

  (g) Each individual treatment plan shall include, at a minimum, the following:

(1) Consumer problems to be addressed.

(2) Specific goals written in terms of measurable criteria for proposed outcomes of each identified problem.

(3) Therapeutic activities and their frequency.

(4) Referrals for needed services that are not provided by the program.

(5) Staff persons responsible for working with each identified goal.

(6) Plans for involvement in appropriate support groups.

(7) The consumer's signature indicating that he or she has reviewed and understands the contents of the service plan and any revisions thereafter.

  (h) The program shall have a policy and procedure for recording consumer progress that addresses, at a minimum, the following:

(1) A consumer record shall be completed for each therapeutic activity and its relationship to the service plan.

(2) The date and identity of the person making the entry.

(3) Entries shall be made after each consumer contact.

  (i) The program shall have written policies and procedures for discharge planning that shall include, but not be limited to, the following criteria:

(1) The discharge plan shall be reviewed by the consumer.

(2) The discharge summary shall include, at a minimum, indicators of the following:

(A) The consumer's progress in achieving outcomes for each goal of the treatment plan.

(B) A final evaluation.

(C) Recommendations for care after discharge.

(3) The discharge summary shall be completed within thirty (30) calendar days following discharge.

(Division of Mental Health and Addiction; 440 IAC 4.4-2-4.5; filed Feb 11, 2002, 4:30 p.m.: 25 IR 2223; readopted filed Apr 7, 2008, 3:40 p.m.: 20080507-IR-440070745RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA)