The program will have written policies and procedures for the following:

1. (1)

   1. (A) The program shall comply with state and federal regulations governing confidentiality of alcohol and drug abuse client records and other client-identifying information.

   2. (B)

      1. (i) Existing federal regulations include the Health Insurance Portability and Accountability Act and 42 C.F.R. pt. 2.
      2. (ii) Both regulations provide for safeguarding files or other client-identifying information from disclosure or access by unauthorized individuals, and require that records be maintained in a secure manner.
      3. (iii) The Office of Alcohol and Drug Abuse Prevention shall review records for the purpose of monitoring execution of the policies and standards required by these rules;

2. (2) Documentation shall not contain:

   1. (A) Slang;
   2. (B) Technical jargon; or
   3. (C) Abstract terms;

3. (3)

   1. (A) Errors in the treatment chart should never be corrected:

      1. (i) With “white-out” or marker;
      2. (ii) By pasting paper over the error; or
      3. (iii) By any other method which would obliterate the original words.

   2. (B)

      1. (i) When an error is corrected, the original text must remain readable.
      2. (ii) A single line is to be drawn through the error, the correct information added with the date and initials of the person making the correction;
4. (4) No documentation shall be signed and dated prior to completion;

5. (5) The program's treatment services, lectures, and written material shall be:

   1. (A) Appropriate to the clients served;
   2. (B) Age-appropriate; and
   3. (C) Easily understood by clients;

6. (6) There is documentation of planned programs, consistent with the needs of the clients, for social, educational, and recreational activities for all clients for:

   1. (A) Daytime;
   2. (B) Evenings; and
   3. (C) Weekends;

7. (7)

   1. (A) The program shall retain all documentation for at least six (6) years and shall ensure that all individual client records are disposed of in a secure manner.

   2. (B) The written policies and procedures shall ensure:

      1. (i) The program exercises its responsibility for safeguarding and protecting loss, tampering, or unauthorized disclosure of information, and the file cabinets and files are marked “CONFIDENTIAL”;
      2. (ii) Client case records are readily accessible to those individuals specifically authorized by program policy;
      3. (iii) Content and format of client records are kept uniform;

      4. (iv) Entries in the client record are:

         1. (a) (a) Signed;
         2. (b) (b) Dated; and
      5. (c) (c) Time-noted;
      6. (v) Client records which are part of an unresolved audit, investigation, or other legal process shall be maintained for a minimum of six (6) years, or at least until the audit, investigation, or other legal process is resolved;
      7. (vi) Forms in each client record are bound in such a manner to minimize accidental loss;
      8. (vii) Allergies and/or other serious conditions are flagged on the outside of the record;
      9. (viii) The program shall make records available to the office upon request; and
      10. (ix) Each new admission, readmission, or transfer admission is interviewed, and the interview is documented in the client record;
8. (8) The program has a standardized screening protocol to determine applicants’ eligibility and appropriateness for admission to treatment;

9. (9) The program has a uniform intake process, and documentation shall include:

   1. (A) The types of information to be gathered on all clients;
   2. (B) Procedures to be followed when accepting referrals;
   3. (C) Offering case management, withdrawal risk assessment, outpatient services, education, and referral to another licensed program when the program is at full capacity; and
   4. (D) Procedures for the provision of emergency services (i.e. after hour admission, medical emergencies) and other special circumstances;

10. (10)

    1. (A) A client handbook is made available to all clients and a receipt must be in the client record.

    2. (B) The client handbook shall include the following:

       1. (i) A written statement of the services provided by the program and a description of the kinds of problems and types of clients the program can serve;
       2. (ii) A written statement describing admission and discharge procedures;
       3. (iii) A written statement describing living conditions and standards of behavior expected; and
       4. (iv) The organization’s client grievance process;

11. (11)

    1. (A) Personal property inventory shall be taken upon admission to a residential environment.
    2. (B) Items of value shall be securely stored by the program at the request of the client.

    3. (C) The inventory list will include the:

       1. (i) Stored items;
       2. (ii) Date received and returned; and
       3. (iii) Signatures of staff and client; and
12. (12) The program shall provide a specialized plan for treatment by assessment and then addressing the specialized needs of each client of the program.

Codification Notes: Health Insurance Portability and Accountability Act of 1996 was enacted as Pub. L. No. 104-191.