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New York State Office of Alcoholism and Substance Abuse Services Link to New York State Office of Alcoholism and Substance Abuse Services Home Page

OUTPATIENT CHEMICAL DEPENDENCY SERVICES FOR YOUTH
PROGRAMS AND SERVICES

[Statutory Authority: Mental Hygiene Law Sections 19.09, 19.15]

Notice: The following regulations are provided for informational purposes only. The Office of Alcoholism and Substance Abuse Services makes no assurance of reliability. For assured reliability, readers are referred to the Official Compilation of Rules and Regulations.

Sec.
823.1 Background and intent
823.2 Legal base
823.3 Applicability
823.4 Definitions
823.5 Program services
823.6 Admission and retention criteria
823.7 Prohibition on discrimination
823.8 Treatment of minors
823.9 Intake and admission procedures
823.10 Comprehensive evaluation
823.11 Individual treatment plan
823.12 Discharge planning
823.13 Review and revision of treatment plans
823.14 Patient records
823.15 Confidentiality of records
823.16 Personnel
823.17 Staffing
823.18 Utilization review
823.19 Quality assurance
823.20 Physical plant and equipment
823.21 Additional locations
823.22 Standards pertaining to Medicaid reimbursement
823.23 Waiver
823.24 Implementation procedures OASAS certified providers

Section 823.1 Background and intent.

(a) These regulations set forth minimum standards for clinic services discretely certified as outpatient chemical dependency for youth programs. Such programs provide treatment to:

(1) chemically dependent youth in a treatment setting supporting abstinence from alcohol and/or substances, except when a substance is used in accordance with a lawful prescription; and

(2) youth who demonstrate impairment because of alcohol and/or substance abuse by a family member or significant other.

(b) It is the intent of these regulations that outpatient chemical dependency programs for youth shall provide a range in intensity of clinic services appropriate and necessary to each individual through individualized treatment planning, but shall be distinct from intensive rehabilitation services as described elsewhere in this Title.

(c) It is the intent that all outpatient chemical dependency programs for youth shall extend services to significant others of chemically dependent persons, in recognition of alcoholism and substance abuse as family diseases. This Part provides for the treatment of significant others, including family members of all ages, for the adverse effects of close relationships with a person suffering from a chemical dependency.

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823.2 Legal base.

Mental Hygiene Law, sections 19.09(b) and 19.15(e).

823.3 Applicability.

These regulations apply to any person or entity organized in accordance with Part 372 of this Title, operating pursuant to the provisions of this Title and certified by the Office of Alcoholism and Substance Abuse Services to operate an outpatient chemical dependency program for youth.

823.4 Definitions.

For purposes of this Part, the following terms are defined:

(a) Chemical dependency or chemically dependent means the use of alcohol or substances, or both, to the extent that there is evidence of physical or psychological dependence and/or impairment of normal adolescent development in one or more of the major life areas (social, emotional, family, educational, vocational, physical).

(b) Outpatient chemical dependency program for youth (OCDY) means an alcohol and drug-free setting supporting abstinence from alcohol and/or other substances of abuse that provides active treatment to individuals who meet the admission criteria as provided in section 823.6 of this Part through multi-disciplinary clinical services designed to achieve and maintain an abstinent lifestyle or to provide treatment to youth whose normal adolescent development in one or more major life areas has been impaired as a result of the use of alcohol and/or other substances by a family member or significant other.

(c) Youth means a person who is less than 18 years of age on or before the date of admission to the OCDY program.

(d) Minor means a person who is under 18 years of age but does not include a person who is the parent of a child or has married or is emancipated.

(e) Qualified health professional means a person who meets the criteria set forth in section 372.3(h) of this Title, or is a substance abuse counselor who has been issued a credential by the office pursuant to Part 872 of this Title.

(f) Governing authority means the person or group of persons having full legal authority and responsibility for the overall operation of a facility.

(g) The following units of service are defined:

(1) brief visit means a period of direct patient evaluation, therapy or counseling extending at least 15 minutes but less than 30 minutes;

(2) regular visit means a period of direct patient evaluation, therapy, or counseling extending at least 30 minutes; and

(3) collateral visit means a period of direct evaluation, therapy, or counseling extending at least 30 minutes.

(h) Social services means the use of social work methods for the identification, prevention, assessment and management of a person's affairs of daily living associated with his or her alcohol and/or substance abuse.

(i) Office means the Office of Alcoholism and Substance Abuse Services.

(j) Commissioner means the Commissioner of the Office of Alcoholism and Substance Abuse Services.

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823.5 Program services.

(a) An OCDY shall operate at least five days per week providing structured treatment and rehabilitation services in accord with individual treatment plans. Evening and weekend hours shall be available for patients, their families and significant others on an as needed basis.

(b) Each OCDY program must directly provide:

(1) group and individual counseling supervised by a qualified health professional;

(2) education about, orientation to, and opportunity for participation in, available and relevant self-help groups;

(3) education about alcohol and drugs;

(4) AIDS education, including notice to patients that confidential HIV testing and counseling will be made available upon request by a patient;

(5) family services and/or counseling for family members and significant others, supervised by a qualified health professional;

(6) comprehensive evaluations as defined in section 823.10 of this Part; and

(7) individualized treatment planning as defined in section 823.11 of this Part.

(c) Each program must make the following support services available, either direct or through formal written agreements with other appropriately licensed providers:

(1) medical/surgical treatment, including but not limited to prenatal, perinatal services, and pediatric services;

(2) emergency services seven days per week, 24 hours per day, including but not limited to detoxification and acute psychiatric services;

(3) residential services;

(4) for youth over age 16 who are not appropriate for high school programs, vocational assessment and referral services to vocational and other appropriate programs aimed toward development of independent living skills;

(5) academic, remedial, physical and vocational education, as appropriate, and as required by law;

(6) routine medical and nursing services, as appropriate, including diagnostic X-ray, laboratory and other diagnostic services;

(7) HIV testing, if requested by the patient, in compliance with Part 309 or 1072 of this Title;

(8) parenting skills training;

(9) conflict resolution and dispute mediation;

(10) active and quiet recreation; and

(11) social services.

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823.6 Admission and retention criteria.

No youth or family member or significant other shall be admitted until a clinical staff member has documented the criteria listed under subdivision (a) of this section. No youth shall be retained in treatment until a clinical staff member has documented a diagnosis in accordance with criteria listed under subdivision (b) of this section.

(a) Admission. A youth, family member or significant other, shall be admitted to an OCDY, and a comprehensive evaluation shall be undertaken, if a qualified health professional determines, after face-to-face contact with the individual, that:

(1) the youth is less than 18 years of age, except that admission of individuals up to age 21 is allowed in an OCDY if the individual's development indicates that treatment in an OCDY is clinically appropriate;

(2) the youth, family member or significant other, needs outpatient chemical dependency for youth services;

(3) there is a reasonable expectation that the application of OCDY treatment services will result in an improvement in the individual's current level of functioning;

(4) the OCDY program is capable of providing the chemical dependency services the individual may require; and

(5) the youth, family member or significant other does not need acute hospital or psychiatric care, residential treatment or emergency services.

(b) Retention in treatment. A youth, family member or significant other shall be retained in treatment if, based upon the comprehensive evaluation, described in section 823.10 of this Part, a qualified health professional determines that the following criteria have been met, and a program director or designee approves the qualified health professional's determination:

(1) the individual has a diagnosis of a psychoactive substance use disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) of the American Psychiatric Association, or any subsequent revision thereof or amendment thereto; and/or

(2) the individual has a diagnosis supported by documented evidence referenced by the use of the Severity of Psychological Stressors Scale: Children and Adolescents contained in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) of the American Psychiatric Association, or any subsequent revision thereof or amendment thereto, that shows impairment of normal adolescent development in one or more major life areas (social, emotional, family, educational, vocational, physical) due to a relationship with a family member or significant other who has abused or is abusing alcohol and/or other substances.

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823.7 Prohibition on discrimination.

(a) No individual shall be discriminated against in admission or treatment on the basis of sponsorship, race, creed, sexual orientation, color, national origin, gender, disability, marital status, HIV status, pregnancy, or the lack of family or significant other willing to participate in the treatment process.

(b) Past criminal or delinquent behavior or the presence of a co-existing psychiatric disorder shall not be the sole basis for denying admission. Admission procedures shall provide for an assessment of a youth's prior involvement in behavior which was dangerous to self or others and the ability of the program to provide services to such youth.

(c) The reasons for denial of any admission must be documented in a written record kept by the OCDY program for a period of 10 years.

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823.8 Treatment of minors.

(a) In treating a minor the important role of the parents or guardians of the minor shall be recognized. Steps shall be taken to involve the parents or guardians in the course of treatment, and consent from such persons for minors shall be required, except as otherwise provided by law or subdivision (b) of this section.

(b) If in the judgment of a physician, parental or guardian involvement and consent would have a detrimental effect on the course of treatment of a minor who is voluntarily seeking treatment, or if a parent or guardian refuses to consent to such treatment, and the physician believes that such treatment is necessary for the best interests of the child, such treatment may be provided to the minor by a licensed physician, or persons operating under their supervision, without the consent or involvement of the parent or guardian. The minor shall be required to sign a form indicating that the treatment is being voluntarily sought. The signed form shall be included in the minor's clinical record. Such physician shall fully document the reasons why the requirements of this section regarding parental or guardian consent were dispensed with in the minor's clinical record.

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823.9 Intake and admission procedures.

(a) By no later than the second visit, determination as to admission based on criteria listed in section 823.6 of this Part must be made. If a youth requires services other than those an OCDY program can provide, referral to appropriate services shall be made.

(b) By no later than the second visit, a staff member who is a qualified health professional shall be assigned to the patient, and shall be responsible for the comprehensive evaluation described in section 823.10 of this Part and for developing the individual treatment plan described in section 823.11 of this Part.

(c) Within 30 days of admission, the following shall be accomplished:

(1) the comprehensive evaluation must be completed;

(2) a primary counselor must be assigned to the youth; and

(3) the individual treatment plan must be prepared.

(d) During this 30-day period, at least four face-to-face visits with the youth must be scheduled. Such visits may include group counseling sessions.

(e) Initial treatment. While gathering information necessary for the comprehensive evaluation and to engage the youth during this 30-day period, the OCDY program should involve the youth in orientation, education, and therapeutic recreational activities, some combination of individual and/or group counseling, and/or other clinical services, based upon problems and needs identified in the admission assessment.

(f) Referral. If the comprehensive evaluation indicates that a youth needs services beyond the capacity of the OCDY program to provide, either alone or in conjunction with another program, referral to appropriate services shall be made. Identification of and justification for such referrals shall be documented in the patient record.

(g) Persons not in need of treatment. A youth found not to be in need of chemical dependency services, either upon completion of a comprehensive evaluation or earlier, should be given information about self-help groups and other appropriate services and programs that are available in the community as well as any information about the risks of alcohol and substance abuse for everyone, but especially for children of alcoholic and substance abusing persons and others at high risk of alcohol/substance abuse problems.

(h) Education to those family members or significant others who do not need treatment. An OCDY may provide alcohol/substance abuse education and collateral services to family members or significant others of a youth in treatment without admitting such family members or significant others as patients, under the following conditions:

(1) such family members or significant others are found not to need individualized evaluation and treatment services;

(2) no such individualized services are provided; and

(3) no third party is billed for the educational services provided.

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823.10 Comprehensive evaluation.

(a) The goal of the comprehensive evaluation shall be to identify and assess the characteristics and condition of the youth necessary to enable the program to accomplish the following:

(1) ascertain the appropriate care that will meet the youth's needs with the least disruption to the youth's life;

(2) formulate an individual treatment plan; and

(3) formulate a family treatment plan that establishes goals for the family unit when individuals are being served as members of a family.

(b) Performance.

(1) Each evaluation shall be coordinated by the primary counselor who is a qualified health professional under the supervision of the program director or designated clinical supervisor, and the program physician. Persons other than qualified health professionals may conduct examinations and interviews as part of evaluations under the supervision of such professionals and may participate in the formulation of conclusions to the evaluation.

(2) A written report, as described in subdivision (c) of this section, containing specific conclusions shall be prepared for each evaluation. The report shall bear the names of the staff members who participated in evaluating the youth and must be signed by the primary counselor responsible for the evaluation.

(3) Each evaluation shall be completed within 30 days of admission.

(4) Each evaluation shall be based in part on clinical interviews with the patient.

(5) An evaluation shall also include interviews with family members or significant others, if possible and appropriate.

(6) In performing evaluations, staff members shall make every reasonable effort to be sensitive to the socio/cultural background and gender of the youth.

(c) Content. Each evaluation shall be comprehensive and shall include a written report of findings and conclusions addressing each of the following areas:

(1) alcohol and/or drug use and history;

(2) history of previous attempts to abstain from alcohol and/or drugs and previous treatment experiences;

(3) mental status examination; and

(4) comprehensive psychosocial history, including but not limited to:

(i) legal involvements;

(ii) education and literacy, and employment when applicable;

(iii) relationships with family members, peers and significant others;

(iv) history of the use of alcohol and other drugs by family members, significant others and by peer group; and

(v) the impact of chemical dependency on the family and/or significant others; and

(5) a complete physical examination, on site where the OCDY program has capacity to do so, or by referral, which shall include but not be limited to:

(i) biochemical screen for drugs of abuse;

(ii) assessment of prescribed medication;

(iii) review of vaccination status;

(iv) assessment for trauma; and

(v) screening for sexually transmitted diseases, hepatitis B, and tuberculosis;

(6) if a patient has had a complete physical examination within the last 60 days, results of that physical may be used if available; provided, however, that if the prior physical did not include all required information, or is unavailable, the missing information must be obtained.

(d) All information obtained during the comprehensive evaluation must be reviewed by a multi-disciplinary team composed of the primary counselor, clinical supervisor, program director or designee, program physician and other appropriate staff.

(e) If requested by the patient, HIV related testing and counseling shall be provided, pursuant to Part 309 or 1072 of this Title.

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823.11 Individual treatment plan.

(a) A written individual treatment plan shall be designed and shall take into account cultural and social factors as well as the particular characteristics, conditions and circumstances of each patient.

(b) Preparation.

(1) As required in section 823.9 of this Part, the plan must be developed within 30 days by the primary counselor.

(2) The plan must be developed in consultation with the patient and his/her parent or guardian or significant other, unless the patient is not a minor or is a minor being treated without parental consent pursuant to section 823.8 of this Part, in which case the plan must be developed in consultation with the patient and any significant other the patient chooses to involve.

(3) The plan must be reviewed by a multi-disciplinary team composed of the primary counselor, the clinical supervisor, the program director or designee, the program physician and any other appropriate staff.

(4) All clinical staff who participate in preparing or reviewing the plan shall have their names recorded on it. The primary counselor and the program physician who participate in reviewing the plan shall both sign the plan.

(c) Content. The individual treatment plan must specify at least the following:

(1) the long-term goals of the treatment to be provided;

(2) short-term goals and time-frames for achieving them, set out in detail to serve as benchmarks of the patient's progress toward long-term goals, including but not limited to:

(i) alcohol and/or substance abuse abstinence;

(ii) marital and/or family relations;

(iii) interpersonal relations and other social functioning;

(iv) educational, vocational, and/or employment goals;

(v) preventive HIV education;

(vi) health and nutrition; and

(vii) relapse prevention; and

(3) schedule of therapies, activities, and experiences, including individual and group counseling, related to stated goals;

(4) counseling of family or significant others, if appropriate; and

(5) discharge planning.

(d) Each plan must contain a schedule for reviewing the patient's attainment of treatment goals as required in section 823.13 of this Part.

(e) Each plan must contain a mechanism for ensuring coordination of treatment plans and services for all related patients, if more than one member of a family, or a patient and a significant other, have been admitted to treatment.

(f) Where a service is to be provided by any other program or facility off site the plan must contain a description of the nature of the service and a record that referral for such service has been made.

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823.12 Discharge planning.

(a) The discharge plan to be included in every comprehensive individual treatment plan shall include:

(1) the youth's need for continued services for health or psychiatric problems, and/or other needs which have been identified in the comprehensive evaluation and over the course of treatment; and

(2) the family's need for continued services.

(b) In the event a youth is discharged from or chooses to leave treatment before completing the planned course of treatment, the discharge plan must include referrals or referral options for continued services.

(c) A discharge plan shall be prepared in consultation with the patient, his or her parent or guardian or significant other, unless the youth is not a minor or is a minor being treated without parental consent and in compliance with section 823.8 of this Part, and with any significant other the patient chooses to involve.

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823.13 Review and revision of treatment plans.

(a) Schedule of reviews. A multi-disciplinary team composed of the primary counselor, clinical supervisor, program director or designee, program physician and any other relevant staff must review and, if necessary, revise each individual treatment plan as follows:

(1) no later than 90 days after the patient's admission, and every 90 days thereafter (i.e., on a quarterly basis) as long as the patient remains in treatment;

(2) every fourth such quarterly review shall be a comprehensive evaluation, as described in section 823.10 of this Part; and

(3) whenever an event occurs that, in the opinion of the primary counselor, will significantly affect the patient's treatment and recovery.

(b) Content of reviews. Each review shall address, at a minimum, the following:

(1) whether the patient is receiving the appropriate level of care or should be referred to a different agency or program for a different type or level of care; and

(2) what adjustments to the plan, if any, may be necessary in light of the patient's progress, changed circumstances, or lack of progress.

(c) The conclusion of each review and any revisions to the treatment plan shall be documented in writing. (d) To the extent possible, treatment plans of all members of a family shall be reviewed and revised, if necessary, by the same multi-disciplinary team at the same time.

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823.14 Patient records.

(a) An OCDY shall maintain an individual record for each patient admitted to the program.

(b) Each record must include, at a minimum, the following:

(1) the patient's name or code, date of birth, sex, race, marital status and residence;

(2) notes and results of the initial admission evaluation, including documentation that:

(i) the patient meets the criteria for initial admission described in section 823.6 of this Part;

(ii) the patient was informed of the voluntary nature of treatment;

(iii) if the patient is a minor being treated without parental consent, that the provisions of section 823.8 of this Part have been met; and

(iv) the patient was given a copy of the program rules and regulations; and

(3) detailed documentation of the comprehensive evaluation, including results of the patient's physical examination;

(4) the individual treatment plan;

(5) the discharge plan;

(6) documentation that includes a progress note after each counseling session, noting the date, type, nature and length of the counseling session and progress or regression of the patient in relation to the patient's treatment plan;

(7) documentation of the quarterly review of the treatment plan, as required by section 823.13 of this Part;

(8) documentation of other reviews required by this Part and any determinations or treatment plan amendments made as a result of such reviews, stating the reasons therefore;

(9) documentation of recommendations, referrals and services provided for the patient's general health or for other special needs, including coordination with other agencies, as included in the treatment plan, and notes on the patient's progress with such other agencies, as well as other incoming and outgoing correspondence about the patient;

(10) results of any urine or breath testing performed;

(11) notes of any disclosure of HIV status, as required by Parts 309 and 1072 of this Title, as applicable;

(12) statement of the reasons for discharge or termination of treatment and whether or not such termination was against medical advice;

(13) documentation of contacts with a patient's family and/or significant other(s); and

(14) signed releases of information.

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823.15 Confidentiality of records.

(a) All records that would identify a youth as a patient of an OCDY program either directly or indirectly, whether related to referral, diagnosis, treatment or HIV status, are confidential and may only be released in accordance with the requirements of Federal confidentiality regulations (42 CFR part 2) and Parts 309 and 1072, respectively, of this Title.

(b) Child abuse reporting.

(1) Any staff member of an OCDY program or unit who has reasonable cause to suspect that a child coming before him or her is an abused or maltreated child or where the parent, guardian, custodian or other person legally responsible for such child comes before him or her in his or her professional or program capacity and states from personal knowledge, facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child shall immediately report such suspected child abuse or maltreatment to the OCDY program or unit director or his or her designee. If the staff member is him or herself a mandated reporter, he or she must personally make a report as required by law.

(2) The OCDY program or unit director or designee shall immediately report by telephone the suspected child abuse or maltreatment to the Statewide Central Register of Child Abuse or Maltreatment unless the appropriate local plan for the provision of child protective services provides for oral reports to the local child protective service. The OCDY program or unit director or designee or staff member shall submit within 48 hours a written report to the local child protective service of the suspected child abuse or maltreatment on the forms established therefore.

(3) Such reports shall be submitted without regard to whether the patient who is alleged to have abused or maltreated or neglected a child consents to such reporting and without regard to whether such alleged abused or maltreated child who may be receiving services consents.

(4) Additional information beyond initial reports may only be disclosed with proper consent or an appropriate court order.

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823.16 Personnel.

(a) The OCDY program shall employ an adequate number of appropriately qualified staff to address the needs of admitted patients.

(1) The program shall make affirmative efforts to assure that staff reflect and/or are sensitive to cultural, ethnic and language characteristics of the population served.

(2) When an OCDY program chooses to treat mental illness of patients in addition to their chemical dependency, the program shall continuously have qualified staff consistent with these additional service needs of patients.

(3) The OCDY program shall continuously employ administrative, maintenance and support staff in sufficient numbers to maintain the program in clean and working order, to minimize the need for treatment staff to perform nontreatment functions and to optimize operational efficiency.

(4) An OCDY program may utilize students and trainees, on a salaried or non-salaried basis, in addition to staff required by regulation, if such students or trainees are provided close professional staff supervision and necessary didactic education from both internal and external sources.

(b) All persons providing services to patients, family members, and/or significant others in the OCDY program shall be employed directly by the governing authority or by a contractor approved by the OASAS.

(c) All staff members providing services as members of professions, the practice of which is by law required to be licensed and registered, shall be licensed and registered and current documentation of same shall be retained on file by the OCDY program.

(d) Direct care staff who are not qualified health professionals shall have qualifications appropriate to their assigned responsibilities as set forth in the OCDY program's personnel policies and shall be subject to appropriate professional staff supervision and continuing education and training.

(e) All other staff shall have qualifications appropriate to their assigned responsibilities as set forth in the OCDY program's personnel policies and shall be subject to appropriate supervision.

(f) Direct care staff members who do not have one year of experience in the care and treatment of chemically dependent youth at the time of initial employment shall during their first year of employment receive documented training and supervision that at a minimum addresses all the areas of competency and knowledge listed in Parts 395 and 1015 of this Title.

(g) Each OCDY program shall develop and implement a plan for ongoing staff training, development and continuing education which shall apply to all staff providing direct care to patients. Such plan shall include, but not be limited to:

(1) chemical dependency specific intake, assessment, treatment planning, ethics, case supervision, family counseling, and relapse prevention;

(2) adolescent growth and development, including but not limited to social, emotional, family, educational, vocational, and physical;

(3) training and development concerns in case conferences;

(4) resolution of deficiencies noted in routine performance evaluations and quality assurance reviews;

(5) socio/cultural sensitivity;

(6) orientation, education and periodic re-education of all employees regarding acquired immune deficiency syndrome, HIV-related illness, and HIV infection and about universal precautions against exposure to significant risk of contracting or transmitting HIV infection, as required by Parts 309 and 1072 of this Title;

(7) overview of alcoholism and substance abuse; and

(8) foundations of prevention.

(h) The qualifications, training and experience of each employee shall be verified with previous employers, educational institutions and other sources at the time of initial employment and such verification shall be filed in the person's personnel file.

(i) Personnel in possession of licenses, registrations or other credentials which are subject to routine expiration shall be required to provide evidence of renewal, as appropriate, which shall be filed in personnel files.

(j) Facilities using volunteers shall have written policies and procedures governing the use of volunteers including policies and procedures for recruitment, orientation, training, assignment, supervision and evaluation. Such facilities shall also conform to the following:

(1) an appropriately qualified staff member shall be designated to coordinate and supervise volunteer services;

(2) an individual record shall be maintained for each volunteer that shall include at least the following:

(i) his or her application;

(ii) a record of orientation to the program and to pertinent policies and procedures, especially those concerning confidentiality of patient information;

(iii) documentation of ongoing and regularly scheduled training and supervision;

(iv) regular evaluations of performance and;

(v) a record of assignments and of hours worked; and

(3) volunteers may provide direct services to patients only if they meet all requirements applicable to paid staff or are in an established degree program or an alcoholism or substance abuse counselor credentialing training program; and

(4) all volunteers providing direct services to patients must be under the direct supervision of qualified staff.

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823.17 Staffing.

(a) Staffing must be adequate to ensure the provision of comprehensive services by a multi-disciplinary team and clinical supervision of all direct care staff on a regular basis. Staffing and staff to patient ratios must be sufficient to provide the necessary intensity and frequency of services needed by patients, and must at a minimum, include:

(1) a full-time clinical program director who is a qualified health professional, with at least two years experience in the treatment of alcohol or substance abuse, one year in provision of services to adolescents and one year in program administration and/or supervision;

(2) one full-time credentialed alcoholism counselor and/or credentialed substance abuse counselor, trained and experienced in treating adolescents;

(3) one full-time equivalent qualified health professional direct care staff member who is qualified in a discipline other than alcohol and/or substance abuse counseling; and

(4) a physician licensed by New York State and board-eligible in psychiatry or other relevant specialty with experience or special training in the treatment of alcohol or substance abuse who is available on-site for at least one hour per week for each 10 patients seen once per week or more, in the OCDY program.

(b) Of the qualified health professionals staffing the OCDY, at least one must have at least one year of experience in family counseling.

(c) There must be at least one full-time equivalent paid direct care staff member for each 20 patients who are regularly provided treatment services.

(d) Qualified health professionals must provide at least 50 percent of all direct care staff hours; any such hours provided by other staff must be provided by persons in relevant training and under the supervision of a qualified health professional.

(e) Full-time paid staff of the OCDY program shall provide at least 50 percent of all direct care staff hours.

(f) There shall be at least one employee certified in first aid and cardiopulmonary resuscitation.

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823.18 Utilization review.

(a) Each chemical dependency for youth program shall establish a utilization review plan in accordance with this section. The plan shall be reviewed and approved by the office. An independent professional may perform both utilization review and quality assurance review. If not, the OCDY program shall meet this requirement as follows:

(1) the program may perform its utilization review and quality assurance processes internally; or

(2) the program may enter into an agreement with a certified ambulatory care program(s) to complete its utilization review process. If any outside group has access to actual patient records, it must agree in writing that it is bound by the Federal confidentiality regulations, that it will maintain no information containing patient identifying data and that it will make no further disclosure of patient identifying information; and

(3) whether performed internally or through external agreement, at least one of the committee members must have a minimum of one year experience in treating adolescents.

(b) Required committee members. The committee responsible for utilization review must be composed of at least:

(1) one qualified health professional physician;

(2) one qualified health professional certified social worker or qualified health professional registered nurse; and

(3) one alcohol or substance abuse counselor, provided the counselor has adequate experience and knowledge about the diagnoses to be reviewed.

(c) Optional committee members. Additional members of professional staff may participate in the activities of the committee.

(d) No member shall participate in the committee's deliberations relative to any patient he or she is treating directly.

(e) An appropriate method of identifying patients and staff which appropriately maintains confidentiality in the records of the committee shall be maintained.

(f) Operation of review committee. Criteria for admission and continued stay in each program shall be as stated in this Part. Utilization review shall be conducted monthly in accordance with the following:

(1) a 100 percent sample of patients whose treatment has passed one year from initial admission during the previous month;

(2) a random sample to be drawn from all cases where a decision to retain in treatment as described in section 823.6(b) of this Part was made during the previous month, but in no event shall less than 25 percent of such cases be reviewed; and

(3) a random sample to be drawn from all cases which have not been subjected to utilization review over the previous three-month period, but in no event shall less than 25 percent of such cases be reviewed.

(g) If it appears, on initial review, that a patient does not meet applicable criteria, the primary counselor shall respond to the full committee with supporting medical record material within one working day of notification of such finding.

(h) If, after review of the additional information submitted pursuant to subdivision (g) of this section, the final determination by the entire committee is that the individual does not meet applicable criteria, an alternate care determination shall be made by the committee.

(1) Services shall be limited to three additional visits to perform final discharge planning and to accomplish appropriate referral when necessary.

(2) If the alternate level of care needed is unavailable, services may continue until appropriate alternate service is arranged. Any such patient's record shall be reviewed by the entire committee each succeeding month.

(i) The plan shall provide that if alternate care determinations exceed a rate of 10 percent of reviewed cases, the program shall implement 100 percent review of cases subject to the review process for that month. This may necessitate a retrospective review of some cases.

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823.19 Quality assurance.

(a) Each OCDY program shall establish a quality assurance plan for such program in accordance with this section. The plan shall be reviewed and approved by OASAS. A professional standards review organization may perform both utilization review and quality assurance review. If not, the OCDY program shall meet this requirement as follows:

(1) the plan shall include a quality assurance review as part of the utilization review process. The quality assurance review shall, at a minimum, determine that the services being rendered are appropriate, and that additional services are not necessary;

(2) if a review indicates that services are inappropriate or insufficient, the utilization review committee and the responsible staff member shall modify that patient's treatment plan to the mutual satisfaction of both parties;

(3) the quality assurance review process shall be used to indicate trends which can be analyzed for corrective action, as follows:

(i) if deficiencies in quality are found in over 10 percent of the reviews completed, the utilization review committee shall make detailed recommendations for corrective action. The utilization review committee shall develop these recommendations with the director of the program within 30 days after a trend of deficiencies has been identified;

(ii) copies of any such recommendations shall be submitted to OASAS regional office;

(iii) the director of the program shall respond within 10 days to the utilization review committee detailing action he or she plans to take;

(iv) the utilization review committee shall monitor corrective actions to determine if the deficiency incidence has dropped below 10 percent; and

(v) multiple deficiencies related to an individual patient may indicate that an alternate level of care is more appropriate. This question should be considered separately by the utilization review committee; and

(4) the utilization review committee shall hold monthly meetings and shall keep minutes sufficiently detailed to show its decisions and the basis for them.

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823.20 Physical plant and equipment.

(a) The design and furnishings of the physical environment shall provide for privacy, promote human dignity and further the effective operation of all programs.

(b) Each OCDY program shall have at least one main location for the performance of program functions which shall be adequately designed, furnished and maintained to conform to at least the following:

(1) The OCDY program shall maintain separate counseling spaces for chemical dependency-related functions to promote confidentiality and maintain privacy, except that this shall not require the separation of common areas from mental health service areas or health service areas in facilities also certified by the Office of Mental Health, or the Department of Health, respectively.

(2) An adequately furnished waiting area shall be provided near the OCDY program entrance for the comfort and convenience of those waiting for services of the OCDY program, and this area shall include provision for direct staff supervision to control access to the program premises and to prevent entry by unauthorized persons.

(3) Separate individual counseling rooms which afford privacy for interviews between staff and patients shall be provided if staff offices are not suitable or sufficient for this use.

(4) OCDY program staff offices shall be together and distinct from staff offices of staff of other programs.

(5) Small group counseling rooms shall be available in sufficient number to accommodate the number of simultaneously conducted counseling groups required by program and service plans. Each small group counseling room shall:

(i) provide 15 square feet per person expected to participate, but no less than a total of 100 square feet;

(ii) be constructed to prevent sound transmission outside the room; and

(iii) be properly heated and ventilated.

(6) At the discretion of the OCDY program director, small group counseling rooms of the OCDY program may be used by other disability programs when not needed by the chemical dependency program.

(7) At least one large group room shall be available and accessible for purposes such as, but not limited to, chemical dependency education groups, staff meetings, community meetings, and relevant self-help meetings.

(8) Spaces of appropriate size, appropriately furnished and equipped, and near primary program spaces shall be provided as required by the program for medical, nursing, psychology, supervision of patients' children, activity therapy, therapeutic recreation, community competency services and other services with special needs for space, equipment and furnishings. Such spaces need not necessarily be devoted exclusively to OCDY program use.

(9) A separate area in the OCDY program sufficient in size and properly furnished and equipped shall be provided for storage and maintenance of individual patient records. Such space shall ensure confidentiality of records by means of locked file cabinets and doors when the area is not staffed and in use. A single record room for the OCDY program and other disability services may be maintained as long as OCDY program records are maintained separately from other records in conformity with applicable State and Federal law and regulation.

(10) There shall be sufficient numbers of properly cleaned, maintained and supplied restrooms appropriately located throughout the premises to accommodate staff and patients and other users of the building.

(11) There shall be sufficient exits to the exterior of the building to allow the safe evacuation of the OCDY program in the event of emergency.

(12) Spaces at each additional location shall conform to the foregoing to the extent applicable based on the services provided at each such location except that they need not be separate as long as privacy is maintained and a waiting room with supervision is available.

(c) The premises shall be selected, constructed, modified and/or maintained so that the OCDY program is accessible to persons with disabilities in compliance with the Federal Americans with Disabilities Act and applicable State and local laws and regulations.

(d) The premises shall comply with the New York State Uniform Building Construction and Fire Prevention Code (Title 9 NYCRR) sections applicable to occupancy group C1 business unless a more stringent code requirement is established in a locality.

(e) A written certificate of occupancy or equivalent from the local building inspection authority and any other required approvals by other local officials shall be obtained and retained in the records of the OCDY program and provided to the office upon request.

(f) Heat, light, ventilation and cleanliness shall be adequate for the comfort and wellbeing of patients and employees.

(g) Mobile premises and their use shall comply with all applicable laws, regulations and ordinances.

(h) The OCDY program or unit shall maintain at least one-eighth inch scale drawings of all space regularly available indicating the purpose of each interior space.

(1) If the building is shared with other users, building floor plans shall show at least the separation of the OCDY program or unit from other building users and the exit routes to the exterior.

(2) If space or specialized spaces, such as but not limited to, recreation areas and dining areas, are shared with other users, a schedule of their availability to the OCDY program or unit shall also be maintained.

(3) Plans and schedules shall be provided to the office upon request.

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823.21 Additional locations.

(a) A certified or licensed provider of services may operate a chemical dependency program for youth at one or more additional locations with the approval of the office. Such approved additional location(s) shall be listed on the operating certificate or license of the provider of services.

(b) For purposes of this section, additional location means a satellite place for the provision of OCDY, under the supervision of the program staff of the main location of a certified or licensed provider of services and where no more than 2,500 units of service, as defined in section 823.4(h) of this Part, are provided per year; such additional location must be subordinate to and dependent upon the main location of the provider of services for operation, administration and supervisory activities.

(c) Each such additional location shall be approved in circumstances where the provider or* services shows a clear need for the chemical dependency services for youth at the site proposed as well as a financial and programmatic ability to provide the services. The provider of services shall apply for approval to operate the additional location by completing an application prescribed by the office, clearly indicating the characteristics of the space, the program schedule, the staffing and other relevant information. The local governmental unit or local designated agency, as applicable, shall receive notice of the application and have an opportunity to make a recommendation within 14 days.

* "or" probably sb "of"

(d) Each additional location shall have adequate space to allow for the type and volume of services planned at the location. There shall be qualified staffing, to provide the planned type and volume of services during the hours the location is open. Procedures shall be established to insure that utilization review and case supervision shall be conducted by professional staff of the main location.

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823.22 Standards pertaining to Medicaid reimbursement.

(a) Medicaid reimbursement will be available pursuant to regulations of the Department of Social Services governing clinic programs at 18 NYCRR Part 505.

(b) In order to qualify for reimbursement, each occasion of service must be documented in the patient's record as a covered medical service in accord with the following:

(1) in order to qualify for medical assistance reimbursement, each occasion of services must meet the standard established in this Part; and

(2) the service must be provided by program staff as required by this Part.

(c) The patient must be seen at least once by the program physician.

(d) Services to significant others.

(1) An OCDY may provide services to significant others of a person suffering from chemical dependency who are not themselves suffering from chemical dependency but who have been admitted as patients for one or more of the following purposes:

(i) to evaluate and assess the nature and extent of physiological, social or other problems resulting from close personal relationship to such a person;

(ii) for remediation of problems and conditions resulting from close relationship to such a person; and

(iii) to remedy negative influences of the home environment on the chemically dependent person, significant other or both.

(e) Noncovered services under the medical assistance program.

(1) Visits to the premises of an OCDY for the sole purpose of attending meetings of an alcoholics anonymous group or other self-help group are not reimbursable by the medical assistance program.

(2) Any visits which include only companionship, recreation, and/or social activity are not covered by the medical assistance program.

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823.23 Waiver.

(a) The commissioner may grant a waiver of a requirement not specifically required by law, including but not limited to Federal and State Medicaid law, if such commissioner determines that:

(1) meeting the requirement would impose an unreasonable hardship;

(2) the health and safety of patients would not be diminished; and

(3) the best interests of the patients and the program would be served.

(b)

(1) In considering a request for a waiver, the commissioner will consider such factors as special needs of the populations to be served, geographic distances and transportation problems, staff availability, long range plans of the program, alternatives, and any other relevant information.

(2) A request for a waiver must be submitted in writing, must contain substantial documentation to support the need for the waiver and include such other information as the commissioner may require.

(c)

(1) Special limits or conditions may be established by the commissioner in granting a waiver.

(2) A waiver shall be in effect for no longer than the duration of the operating certificate or license held by the OCDY program for which such waiver is granted.

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823.24 Implementation procedures for OASAS certified providers.

(a) Any provider of services with a current valid operating certificate from the office for an outpatient program for alcoholism and alcohol abuse or for an outpatient substance abuse program on the effective date of this Part may be certified as an OCDY program if, prior to April 1, 1988, such provider of services makes a request to the office for such certification by:

(1) submitting a written request for such certification to the commissioner, indicating its intended client population; and

(2) describing how it complies with this Part, including but not limited to compliance with staffing requirements.

(b) The office shall verify that any such applicant has a current operating certificate in good standing and shall determine need, and that the program proposed will be operated in accordance with this Part. Upon such verification the office shall, within a reasonable time, issue an operating certificate to the applicant authorizing the operation of an OCDY.

Date of Last Change: 11/23/94