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 69-11-27 - Provision of Coordination of Patient Care; Post-Admission Assessment and Initial Plan of Care

Current through Register Vol. XLI, No. 28, July 12, 2024
27.1. Each MAT
				program shall develop, implement and maintain current policies and procedures,
				patient protocols, treatment plans and profiles for the treatment of patients
				seeking treatment for medication-assisted treatment.
27.2. Initial Post-Admission Assessments.
27.2.a. All patients undergo an initial
				post-admission assessment in order to determine the patient's condition,
				diagnosis and treatment. The assessment shall be conducted by one or more
				program physicians.
27.2.b. Upon
				admission to a MAT program, each patient shall undergo an initial
				post-admission assessment and the MAT program shall develop an initial plan of
				care. The initial assessment and plan of care shall be completed within seven
				days of the patient's admission.
27.2.c. The initial post-admission assessment
				shall consist of a medical assessment and include documentation of:
27.2.c.1. A physical assessment by a
				qualified medical professional within their scope of practice;
27.2.c.2. A psychiatric assessment, including
				mental status examination and psychiatric history;
27.2.c.3. A personal and family medical and
				health history;
27.2.c.4. All
				current medications, prescription or otherwise;
27.2.c.5. A comprehensive history of
				substance abuse, both personal and family;
27.2.c.6. Determination of current dependence
				on controlled substances;
27.2.c.7.
				A tuberculosis screening;
27.2.c.8.
				A screening test for syphilis;
27.2.c.9. A hepatitis C test;
27.2.c.10. An HIV test to the extent
				voluntarily elected by the patient;
27.2.c.11. An inquiry to and report from the
				Controlled Substances Monitoring Program database;
27.2.c.12. Laboratory tests;
27.2.c.13. A full drug screen;
27.2.c.14. An inquiry whether the patient is
				being treated at any other MAT program;
27.2.c.15. The diagnosis of all conditions,
				including a diagnosis of substance use disorder, including signs and
				symptoms;
27.2.c.16. A copy of the
				report by the referring physician and any medical records from other providers,
				if applicable;
27.2.c.17. The
				dates, amounts and dosage forms for any drugs prescribed, dispensed and
				administered; and
27.2.c.18. Other
				tests as necessary or appropriate, including, but not limited to, CBC, EKG,
				X-ray, pap smear, hepatitis B surface antigen and hepatitis B antibody
				testing.
27.2.d. A
				program physician or supervised physician extender shall perform a physical
				assessment of a patient on the same day that the program physician initially
				prescribes, dispenses or administers a medication-assisted treatment medication
				to a patient. If the patient continues to be treated for substance use disorder
				at the program, an assessment shall be performed at least every 90 days
				thereafter. All assessments shall be performed according to accepted and
				prevailing standards for medical care.
27.2.e. A repeat, full drug screen may be
				completed at 14 days after admission to identify whether the patient is using
				other drugs or substances, including, but not limited to, opiates, methadone,
				buprenorphine, amphetamines, cocaine, barbiturates, benzodiazepines and
				marijuana.
27.2.f. The initial
				post-admission assessment may include laboratory tests conducted by the MAT
				program or by other reliable sources.
27.2.f.1. Laboratory tests that are not
				directly conducted by the MAT program may be provided by the patient's primary
				care physician, other health care providers or by a medical clinic.
27.2.f.2. The MAT program is responsible for
				obtaining and maintaining documentation of required laboratory tests performed
				by an alternative provider. Alternative providers may not supply drug screens
				unless they meet the required quality guidelines, content and timelines
				according to section 34 of this rule.
27.2.f.3. Tests not directly conducted by the
				MAT program at admission shall have been conducted within the 30 days prior to
				the admission in order to be considered a valid assessment of the
				patient.