(1)The Program must provide individual or group motivational counseling sessions and individual advocacy and case management services; all of which must be documented in individual files.
(2)The Program must encourage individuals to remain in services for an appropriate duration as determined by the service plan. Also, the Program must encourage all individuals to enter programs for ongoing recovery.
(3)The Program must refer individuals to self-help groups when clinically indicated and to the extent available in the community.
(4)Individuals fluent in the language and sensitive to the special needs of the population served must be provided as necessary to assist in the delivery of services.
(5)The Program must develop an individualized stabilization plan for each individual accepted for stabilization following clinical assessments for substance use and medical needs. The stabilization plan must be appropriate to the length of stay and condition of the individual and consider safe detoxification, care transition, and medical issue to be addressed. The stabilization plan must include progress notes that:
(a)Identify the problems from the individual assessment and evaluation;
(b)Specify objectives for the stabilization of each identified individual problem;
(c)Specify the stabilization methods and activities to be utilized to achieve the specific objectives desired;
(d)Specify the necessary frequency of contact for the individual services and activities;
(e)Specify the participation of significant others in the stabilization planning process and the specified interventions where appropriate;
(f)Document the individual’s participation in developing the content of the stabilization plan and any modifications by, at a minimum, including the individual’s signature; and
(g)Document any efforts to encourage the individual to remain in the program’s services, and efforts to encourage the individual to accept referral for ongoing treatment.
(6)The individual record must document the individual’s involvement in stabilization activities and progress toward achieving objectives contained in the individual’s stabilization plan. The documentation must be kept current, dated, be legible, and signed by the individual making the entry.
(7)The program must conduct and document in the individual’s record transition planning for individuals who complete stabilization. The transition plan must include:
(a)Referrals made to other services or agencies at the time of transition;
(b)The individual’s plan for follow-up, aftercare, or other post-stabilization services; and
(c)Document participation by the individual in the development of the transition plan.
(8)At transition a stabilization summary and final evaluation of the individual’s progress toward treatment objectives must be entered in the individual’s record.
Rule 415-050-0035 — Stabilization Services,