1. (a) Intake and admission.

   1. (1) Intake procedures, other than initial medical or psychiatric care, shall be performed at a time when the client is mentally and physically capable of comprehension and response.

   2. (2) Intake procedures shall include documentation of:

      1. (i) Drug or alcohol history, or both.
      2. (ii) Consent to treatment.

2. (b) Client records. There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. This shall include, but not be limited to the following:

   1. (1) Consent forms.
   2. (2) Drug and alcohol support plan.
   3. (3) Record of service provided.
   4. (4) Drug and alcohol aftercare plan, if applicable.
   5. (5) Follow-up information.

3. (c) Client management services.

   1. (1) There shall be a written plan that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment following the detoxification process.
   2. (2) The project shall develop a written client aftercare policy.
   3. (3) The project shall develop a written client follow-up policy.

Cross References

This section cited in 31 Pa. Code § 89.621 (relating to inpatient detoxification services).