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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-A. MENTAL HEALTH |
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Chapter 22-A63. CERTIFICATION STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT AND RECOVERY PROVIDERS |
Section 22-A6336. CORE SERVICE: ASSESSMENT/DIAGNOSTIC AND TREATMENT PLANNING
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6336 CORE SERVICE: ASSESSMENT/DIAGNOSTIC AND TREATMENT PLANNING
6336.1 Assessment/Diagnostic and Treatment Planning services include two distinct actions: (1) the assessment and diagnosis of the client and (2) the development of the treatment plan. An Assessment/Diagnostic and Treatment Planning Service may be (1) Initial, (2) Comprehensive, (3) Ongoing, or (4) Brief.
6336.2 The assessment/diagnostic portion of this service includes the evaluation and ongoing collection of relevant information about a client to determine or confirm an SUD diagnosis and the appropriate Level of Care (LOC). The assessment shall serve as the basis for the formation of the treatment plan, which is designed to help the client achieve and sustain recovery. The assessment instrument shall incorporate ASAM client placement criteria.
6336.3 Treatment planning services are required each time an Assessment/Diagnostic and Treatment Planning service is performed. Treatment planning services include the development of a treatment plan or a treatment plan update and necessary referrals.
6336.4 Providers shall use a tool(s) approved by the Department for both the assessment and treatment plan.
6336.5 A treatment plan identifies all services considered medically necessary to address the needs of the client as determined by the assessment. All services shall be delivered in accordance with the treatment plan as part of organized treatment services. The treatment plan shall be person-centered and include:
(a) A substance use disorder diagnosis (and any other diagnoses);
(b) Criteria for discharge from the program based on completion of the established course of treatment, and/or transfer to a less intensive/ restrictive level of care;
(c) A list of any agencies currently providing services to the individual and family including the type(s) of service and date(s) of initiation of those services;
(d) A list of client strengths and needs;
(e) Specific individualized treatment and recovery goals and objectives for each client;
(f) The treatment regimen, including specific services and activities that will be used to meet the treatment and recovery goals;
(g) An expected schedule for service delivery, including the expected frequency and duration of each type of planned service encounter;
(h) The name and title of personnel who will provide the services;
(i) The name and title of the client’s Clinical Care Coordinator, primary substance abuse counselor, and case manager;
(j) A description of the involvement of family members or significant others, where appropriate;
(k) The identification of specific client responsibilities;
(l) The client's identified ASAM Level of Care (LOC);
(m) The client or legal guardian's signature on the plan (if the client refuses to sign the treatment plan, the Clinical Care Coordinator shall document the reason(s) in the treatment plan); and
(n) Signatures of all interdisciplinary team members participating in the development of the treatment plan. The Clinical Care Coordinator’s signature on the treatment plan is required as certification that the services identified on the treatment plan are medically necessary.
6336.6 Initial, Comprehensive, Ongoing, and Brief assessments shall be performed by the following Qualified Practitioners, as evidenced by signature and dates on the assessment document and the treatment plan and in accordance with additional provisions of this section:
(a) Qualified Physicians;
(b) Psychologists;
(c) Licensed Independent Clinical Social Workers (“LICSWs”);
(d)Licensed Graduate Professional Counselors (“LGPCs”) (only for providers not operating under a Human Care Agreement);
(d) Licensed Graduate Social Workers (“LGSWs”);
(e) Licensed Professional Counselors (“LPCs”);
(f) Licensed Marriage and Family Therapists (“LMFTs”);
(g) APRNs;
(h) Certified Addiction Counselors II (“CAC IIs”) (may not diagnose); or CAC Is (may not diagnose).
6336.7 An Initial Assessment/Diagnostic and Treatment Planning service (Initial Assessment) is a behavioral health screening and assessment that (1) identifies the individuals need for SUD treatment, (2) determines the appropriate level of care of SUD treatment, and (3) initiates the course of treatment. For providers operating pursuant to a Human Care Agreement, an Initial Assessment may only be provided by a Department-designated Assessment and Referral Center (ARC), with a Level 1-AR certification. The following provisions apply to an Initial Assessment:
(a) The provider shall use and complete a screening and assessment tool approved by the Department. The screening and assessment should result in identification of the necessary Level of Care (LOC) and an appropriate SUD provider referral, documented in the designated electronic record format.
(b) The provider shall record any medications used by the client;
(c) Staff must have an in-person encounter with the client to conduct the initial assessment;
(d) Providers must obtain and document client’s understanding and agreement, evidenced by the client’s signature, for consent to treatment, assessment, provider choice, the client bill of rights, and release of information;
(e) An Initial Assessment should take at least forty (40) minutes to complete; and
(f) For those providers with a Human Care Agreement with the Department, a maximum of one Initial Assessment may be billed within a thirty (30)-day period.
6336.8 The following provisions apply to the Comprehensive Assessment/Diagnostic and Treatment Planning service (Comprehensive Assessment):
(a) When a client enters his or her first LOC within a treatment episode, the provider shall perform a Comprehensive Assessment to determine his or her treatment and recovery needs. A Comprehensive Assessment consists of a comprehensive assessment and the development of a treatment plan.
(b) A Comprehensive Assessment shall include the use of a Department-approved assessment tool and a detailed diagnostic formulation. The comprehensive assessment will document the client's strengths, resources, mental status, identified problems, current symptoms as outlined in the DSM, and recovery support service needs. The Comprehensive Assessment will also confirm the client's scores on the ASAM criteria and confirm that the assigned LOC is most applicable to the client's needs. The diagnostic formulation shall include presenting symptoms for the previous twelve (12) months, including mental and physical health symptoms, degree of severity, functional status, and differential diagnosis. This information forms the basis for the development of the individualized treatment plan as defined in § 6336.5 of this chapter.
(c) A Comprehensive Assessment must be performed in-person by an interdisciplinary team consisting of the client and at least one Qualified Practitioner with the license and capability to develop a diagnosis. The client’s Clinical Care Coordinator, Certified Addictions Counselor (CAC) and case manager shall also participate in the interdisciplinary team as evidenced by their signature(s) on the treatment plan. A completed treatment plan is required to establish medical necessity.
(d) A Comprehensive Assessment must be completed within seven (7) calendar days of admission to a provider. Providers at Level 3.7-WM must complete a Comprehensive Assessment within forty-eight (48) hours, or prior to discharge or transfer to another LOC, whichever comes first.
(e) Within twenty-four (24) hours of admission at a new LOC, during the period prior to the completion of the Comprehensive Assessment, the provider shall review the Department-approved assessment tool used during the client’s Initial Assessment to develop an Initial Treatment Plan. This Initial Treatment Plan will validate treatment until the Comprehensive Assessment is completed. A Qualified Practitioner as listed in § 6336.6 shall develop the Initial Treatment Plan. The Initial Treatment Plan is considered part of the Comprehensive Assessment and Treatment Planning service.
(f) A Comprehensive Assessment shall take a minimum of one (1) hour to complete.
(g) A Comprehensive Assessment shall include client understanding and agreement, documented by the client’s signature, for consent to treatment, assessment, provider choice, client bill of rights, and release of information.
(h) For those SUD providers with a Human Care Agreement with the Department, no more than one (1) Comprehensive Assessment shall be billed per LOC, and a Comprehensive Assessment cannot be billed on the same day as an Ongoing Assessment.
6336.9 An Ongoing Assessment occurs at regularly scheduled intervals depending on the LOC. The following provisions apply to ongoing assessments:
(a) An Ongoing Assessment, conducted using a tool(s) approved by the Department, provides a review of the client's strengths, resources, mental status, identified problems, and current symptoms as outlined in the DSM.
(b) An Ongoing Assessment will confirm the appropriateness of the existing diagnosis and revise the diagnosis, as warranted. The Ongoing Assessment will also revise the client's scores on all dimensions of the ASAM criteria, as appropriate, to determine if a change in LOC is needed.
(c) An Ongoing Assessment includes a review and update of the treatment plan to reflect the client's progress, growth, and ongoing areas of need.
(d) The Ongoing Assessment is also used prior to a planned transfer to a different LOC and for discharge from a course of service.
(e) The clinical care coordinator shall determine the frequency of ongoing assessments.
(f) An Ongoing Assessment must be completed in-person with the client by an interdisciplinary team, which includes a CAC and at least one Qualified Practitioner with the license and capability to develop a diagnosis. The client’s clinical care coordinator and primary counselor shall participate in the interdisciplinary team.
(g) The Ongoing Assessment shall require a minimum of one (1) hour to complete.
(h) The Ongoing Assessment requires documentation of the assessment tools, updated diagnostic formulation, and the treatment plan update. The diagnostic formulation shall include presenting symptoms since previous assessment (including mental and physical health symptoms), degree of severity, functional status, and differential diagnosis. The treatment plan update shall address current progress toward goals for all problematic areas identified in the assessment and adjust interventions and recovery support services as appropriate.
(i) For providers with a Human Care Agreement with the Department, an Ongoing Assessment cannot be billed on the same day as a Comprehensive Assessment. These providers may bill a maximum of two (2) occurrences per sixty (60) days.
6336.10 A Brief Assessment is a review and documentation of a client’s physical and mental status for acute changes that require an immediate response, such as a determination of a need for immediate hospitalization. The following provisions apply to brief assessments:
(a) A Brief Assessment may also be used to incorporate minor updates to a client’s diagnosis or treatment plan;
(b) A Brief Assessment requires an in-person evaluation of the client by a Qualified Practitioner;
(c) A single service of “Brief Assessment” requires a minimum of forty to fifty (40 – 50) minutes;
(d) A Brief Assessment requires documentation of assessment tool(s), updated diagnostic formulation, and treatment plan update. The diagnostic formulation shall include presenting symptoms since previous assessment (including mental and physical health symptoms), degree of severity, functional status, and differential diagnosis. The treatment plan update shall address current progress toward goals for all problematic areas identified in the assessment and adjust interventions and recovery support services as appropriate;
(e) Providers should reassess the appropriateness of a client’s LOC if frequent brief assessments are needed; and
(f) For providers with a Human Care Agreement with the Department, a Brief Assessment cannot be billed on the same day as Comprehensive Assessment. For these providers, a Brief Assessment must be billed as a minimum of one (1) occurrence. In addition, these providers may bill a maximum of three (3) occurrences in Level 3; a maximum of four (4) occurrences in Level 2; and a maximum of six (6) occurrences in Level 1.