West Virginia Code of State Rules › Agency 69 - Health And Human Resources › Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 69-11 - Medication-Assisted Treatment - Opioid Treatment Programs › Section 69-11-29 - Individualized Treatment Plan of Care

Current through Register Vol. XLI, No. 28, July 12, 2024
29.1. Delivery of patient care and treatment
				interventions shall be based on the needs identified in the individualized
				treatment plan of care.
29.2.
				Within 30 days after admission of a patient, the MAT program shall develop a
				more comprehensive individualized treatment plan of care and attach it to the
				patient's chart no later than five days after the plan is developed. The
				individualized treatment plan of care shall be developed pursuant to the
				guidelines and protocols established by the American Society of Addiction
				Medicine (ASAM), the Center for Substance Abuse Treatment (CSAT) and the
				National Institute on Drug Abuse (NIDA), the American Association for the
				Treatment of Opioid Dependence (AATOD), or such other nationally recognized
				authority approved by the Secretary. The individualized treatment plan of care
				shall include a recovery model based upon the approved guidelines and
				protocols.
29.3. The individualized
				treatment plan of care shall be reviewed by the program physician, primary
				counselor and patient at least every 90 days and documented in the patient
				record. Reviews shall address each of the objectives identified on the initial
				plan of care; document all treatment, counseling, medications and other
				services rendered to the patient; and document the patient's progress. A
				revised plan of care may be implemented with each review. If a new plan of care
				is not implemented, the reasons for such decision should documented in the
				patient's record. Paper and electronic plans of care, including all reviews and
				updates, must be acknowledged by the patient.
29.4. The initial and quarterly
				individualized treatment plans of care shall be developed by the patient, the
				program physician and primary counselor, with input as appropriate from other
				health care providers. The individualized treatment plan of care shall be
				drafted to meet the specific needs of the patient. After the individualized
				treatment plan of care is developed and approved by the patient, the plan of
				care shall be placed in the patient's chart within five days of development.
				The patient shall receive a copy of all of his or her individualized treatment
				plans of care.
29.5. All
				individualized treatment plans of care shall include, at a minimum:
29.5.a. Documentation of the patient's
				diagnoses; the proposed medical treatment and counseling; medication dosages
				and administration;
29.5.b. A
				requirement that the patient regularly attend and participate in the MAT
				program, both medical and counseling aspects, as determined necessary by the
				staff and patient;
29.5.c. The
				identification of triggers for misuse of substances;
29.5.d. The development and use of coping
				strategies for each trigger;
29.5.e. The development of a detailed relapse
				prevention plan;
29.5.f. Meaningful
				follow-up on any identified behavioral health issues;
29.5.g. Follow-up medical or physical issues
				as necessary;
29.5.h. A vocational
				evaluation, formal or informal;
29.5.i. A plan to achieve financial stability
				and independence;
29.5.j. A
				requirement that the patient abstain from use of illicit substances, abuse of
				prescription substances or other substances of abuse;
29.5.k. Documentation of other individual or
				familial issues as relevant and appropriate and the proposed means of
				addressing such issues;
29.5.l. The
				success of the patient's treatment, initiatives and goals;
29.5.m. A description of services and their
				frequency to be provided for the patient and primarily directed to achieve the
				expected goals and outcomes;
29.5.n. The results from initial, monthly and
				random drug tests; and
29.5.o. Such
				other information as recommended by the guidelines and recovery model utilized
				for the patient.