1. (1) Initial determination. An individual seeking residential services shall have an initial determination based upon face-to-face contact plus any other available records and made by a qualified health professional or other clinical staff under the supervision of a qualified health professional; such determination shall document in writing that:

   1. (i) the individual appears to be in need of chemical dependence services; and
   2. (ii) the individual appears to be free of serious communicable disease which can be transmitted through ordinary contact; and
   3. (iii) the individual appears to not need acute hospital care, acute psychiatric care, or other intensive services which cannot be provided in conjunction with residential services or would prevent him/her from appropriate participation in a residential service.
2. (2) Level of care determination. If the initial determination indicates the person is appropriate for residential services, a level of care determination shall be made by a clinical staff member supervised by a qualified health professional no later than 24 hours after the resident’s first on-site contact with the program. The level of care report generated by the level of care protocol must be documented in the resident case record. To be admitted for residential services at the appropriate level of care the individual must meet the level of care protocol criteria for the residential services and must be provided the services which match the resident’s need for either stabilization, rehabilitative, or reintegration services.

3. (3) No individual may be denied admission to a program based solely on the individual's:

   1. (i) prior treatment history;
   2. (ii) referral source;
   3. (iii) pregnancy;
   4. (iv) history of contact with the criminal justice system;
   5. (v) HIV and AIDS status;
   6. (vi) physical or mental disability;
   7. (vii) lack of cooperation by significant others in the treatment/recovery process; or
   8. (viii) medication assisted treatment for opioid dependence prescribed and monitored by a physician, physician's assistant or nurse practitioner.

4. (4) Decision to admit; notice to residents.

   1. (i) If determined appropriate for the residential service, the individual shall be admitted. The decision to admit shall be included in the resident case record, dated and signed by a staff member who is a qualified health professional authorized by program policies to admit individuals; and
   2. (ii) there must be a notation in the resident case record that the resident received a copy of the residential service's rules and regulations, including resident rights, a summary of Federal confidentiality requirements, and a statement that such rules were discussed with the resident and the resident indicated that he/she understood them; and
   3. (iii) all residents shall be informed that admission is on a voluntary basis and that a resident is free to discharge him or herself from the service at any time.
   4. (iv) If the presenting individual is determined to be inappropriate for admission to the residential service, a referral to a more appropriate service must be made, unless the individual is already receiving substance use disorder services from another provider. Individuals deemed ineligible for admission must be informed of the reason.

   5. (v) The admission assessment or decision to admit must contain a statement documenting the individual is appropriate for this level of care, identify the assignment of a named clinical staff member with the responsibility to provide orientation to the individual, and include a preliminary schedule of activities, therapies and interventions.

      (b) Assessment.

5. (1) Prior to admission, all programs must:

   1. (i) conduct a communicable disease risk assessment (HIV/AIDS, tuberculosis, viral hepatitis, sexually transmitted diseases, and other communicable diseases);
   2. (ii) conduct a toxicology screen as clinically appropriate or required by Federal law.

6. (2) As soon as possible after admission, for all residents, programs must:

   1. (i) offer viral hepatitis testing; testing may be done on site or by referral;
   2. (ii) offer HIV testing; testing may be done on site or by referral; individuals on a regimen of pre- or post-exposure prophylaxis must be permitted to continue the regimen until consultation with the prescribing professional occurs.

7. (3) If clinically indicated, as soon as possible after admission, all programs must:

   1. (i) conduct an intradermal skin or blood based tuberculosis test; testing may be done on site or by referral with results as soon as possible after testing; for patients with a positive test result, refer the patient for further tuberculosis evaluation;
   2. (ii) offer testing for other sexually transmitted diseases and referrals for immunization; testing may be done on site or by referral;
   3. (iii) provide or recommend any other tests the examining physician or other medical staff member deems to be necessary including, but not limited to, an EKG, a chest X-ray, or a pregnancy test.
8. (4) As soon as possible after testing programs must explain any blood and skin test results to the resident.

9. (5) Any significant medical issues, including risk for communicable diseases, identified prior to or after admission must be addressed in the treatment/recovery plan and documented in the patient case record. Treatment/recovery plans must include provisions for the prevention, care and treatment of HIV, viral hepatitis, tuberculosis and/or sexually transmitted diseases. If a resident refuses to obtain such care, the provider must have the resident acknowledge in writing that such care was offered but refused.

   (c) Medical history.

10. (1) If the resident has a medical history available and has had a physical examination performed within 12 months prior to admission, or if the resident is being admitted directly to the residential service from another office certified SUD program, the existing medical history and physical examination documentation may be used to comply with the requirements of this subdivision, provided that such documentation has been reviewed and determined to be current and accurate; such determination shall be dated and recorded in the resident record. Notwithstanding the foregoing, the following shall be offered to all patients regardless of a documented history within the previous 12 months: HIV and hep-C testing.

11. (2) Stabilization services.

    1. (i) Within 24 hours after admission, programs providing stabilization services must complete a general assessment which identifies immediate problem areas, substantiates appropriate resident placement and is signed by a qualified professional. If withdrawal symptoms or other potentially life threatening behavior or conditions are present the patient must be assessed immediately for safety by a medical staff person who is working within their scope of practice. A physician must be available by phone at all times to respond to immediate crises.
    2. (ii) Within 24 hours after admission programs providing stabilization services must conclude a medical assessment and, if necessary, a full physical no later than 7 days after admission. All residents shall receive a physical exam by a physician, physician’s assistant or nurse practitioner if they do not have available a medical history and no physical examination has been performed within the prior 12 months. Residents who have a medical history shall receive an evaluation within 7 days.
12. (3) Rehabilitation services. Within seven days after admission, programs providing rehabilitation services must conclude a medical assessment and, if necessary, a full physical no later than 45 days after admission. All residents shall receive a physical exam by a physician, physician’s assistant or a nurse practitioner if they do not have available a medical history and no physical examination has been performed within the prior 12 months. Residents who have a medical history shall receive an evaluation within 21 days.

13. (4) Reintegration services.

    1. (i) Residents admitted to reintegration services should have an identified primary care physician (PCP) in the community and have a physical exam if one has not been completed within the prior 12 months, or, if the resident is admitted to an outpatient SUD clinic (CD-OP) or opioid treatment program (OTP), then within 30 days the reintegration program shall obtain the medical history, physical and treatment plan from the outpatient provider.
    2. (ii) The physical examination shall include review of any physical and/or mental limitations or disabilities which may require special services or attention during treatment.

(a) Admission procedures.