65D-30.0042. Clinical and Medical Guidelines

(1) Screening. This requirement applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with community housing, day or night treatment, intensive outpatient treatment, outpatient treatment, medication-assisted treatment for opioid addiction, and intervention. If the screening is not completed by a qualified professional, then it shall be countersigned and dated by a qualified professional.

(a) Determination of Need and Eligibility for Placement. The condition and needs of the individual shall dictate the urgency and timing of screening; screening is not required if an assessment is completed at time of admission. All individuals presenting for services, voluntarily or involuntarily, shall be evaluated to determine service needs and eligibility for placement or other disposition.

The person conducting the screening shall document the rationale for any action taken and the validated tool used for service determination.

(b) Consent for Drug Screen. If required by the circumstances pertaining to the individual’s need for screening, or dictated by the standards for a specific component, individuals shall give informed consent for a drug screen.

(c) Consent for Release of Information. Consent for the release of information shall include information required in 42 Code of Federal Regulations, Part 2., and may be signed by the individual only if the form is complete.

(d) Consent for Services. A consent for services form shall be signed by the individual prior to or upon placement, with the exception of involuntary placements.

(2) Assessment. This requirement applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with community housing, day or night treatment, intensive outpatient treatment, outpatient treatment, and methadone medication-assisted treatment for opioid addiction. Individuals shall undergo an assessment of the nature and severity of their substance use disorder. The assessment shall include a physical health assessment and a psychosocial assessment.

(a) Physical Health Assessment. (Inmate Substance Abuse Programs operated by or under contract with the Department of Corrections or Department of Management Services are exempt from the requirements of this paragraph. Juvenile Justice Commitment Programs and detention facilities operated by or under contract with the Department of Juvenile Justice are exempt from the requirements of this subsection.)

1. Nursing Physical Screen. An in-person nursing physical screen shall be completed on each person considered for placement in addictions receiving facilities, detoxification, or intensive inpatient treatment. The screen shall be completed by a L.P.N., R.N., A.P.R.N., or physician’s assistant, or physician. When completed by a L.P.N., it shall be countersigned by a R.N., A.P.R.N. physician’s assistant, or physician. The results of the screen shall be documented by the physician, nurse, or physician’s assistant providing the service and signed and dated by that person. If the nursing physical screen is completed in lieu of a medical history, further action shall be in accordance with the medical protocol established under subsection 65D-30.004(7), F.A.C.

2. Medical History. A medical history shall be completed on each individual.

a. For intensive inpatient treatment, the history shall be completed within one (1) calendar day of placement. In cases where an individual is placed directly into intensive inpatient treatment from detoxification or residential treatment, the medical history completed on the individual while in detoxification or residential treatment may be accepted.

b. For residential treatment and methadone medication-assisted treatment for opioid addiction, the history shall be completed within 30 calendar days prior to placement, or within one (1) calendar day of placement.

c. For day or night treatment with community housing, day or night treatment, intensive outpatient treatment, and outpatient treatment, a medical history shall be completed within 30 calendar days prior to or upon placement.

For the components identified in sub-subparagraphs 2.a. and 2.b., the medical history shall be completed by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. Further, the history shall be reviewed, signed and dated by the physician in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. For the components identified in sub-subparagraph 2.c., the medical history shall be completed by the individual or the individual’s legal guardian. For all components, the medical history shall be maintained in the clinical record and updated annually if an individual remains in treatment for more than one (1) year.

3. Physical Examination. A physical examination shall be completed on each individual in the level of service indicated below.

a. For addictions receiving facilities and detoxification, the physical examination shall be completed within seven (7) calendar days prior to placement or two (2) calendar days after placement.

b. For intensive inpatient treatment, the physical examination shall be completed within seven (7) calendar days prior to placement or within one (1) calendar day of placement. In cases where an individual is placed directly into intensive inpatient treatment from detoxification or residential treatment, the physical examination completed on the individual while in detoxification or residential treatment may be accepted.

c. For residential treatment, the physical examination shall be completed within 30 calendar days prior to placement or three (3) calendar days after placement. In cases where an individual is placed directly into residential treatment from detoxification or intensive inpatient treatment, the physical examination completed on the individual while in detoxification or intensive inpatient treatment may be accepted.

d. For methadone medication-assisted treatment for opioid addiction, the physical examination shall be completed prior to administration of the initial dose of methadone. In emergency situations the initial dose may be administered prior to the examination. Within five calendar days of the initial dose, the physician shall document in the clinical record the circumstances that prompted the emergency administration of methadone and sign and date these entries.

For components identified in sub-subparagraphs 3.a.-d., the physical examination shall be completed by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. Further, the examination shall be reviewed, signed and dated by the physician in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. In cases where an individual is placed directly into residential treatment from detoxification or intensive inpatient treatment, the physical examination completed on the individual while in detoxification or intensive inpatient treatment may be accepted.

4. Laboratory Tests. Individuals shall provide a sample for testing blood and urine, including a drug screen.

a. For addictions receiving facilities, inpatient detoxification, intensive inpatient treatment, and residential treatment, all laboratory tests will be performed in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. Further, the results of the laboratory tests shall be reviewed, signed and dated during the assessment process and in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C.

b. For medication-assisted treatment for opioid addiction, blood and urine samples shall be taken within seven (7) calendar days prior to placement or two (2) calendar days after placement. A drug screen shall be conducted at the time of placement. If there are delays in the procedure, such as problems in obtaining a blood sample, this shall be documented by a licensed nurse in the individual record. The initial dose of medication may be given before the laboratory test results are reviewed by the physician. The results of the laboratory test shall be reviewed, signed and dated by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C.

5. Pregnancy Test. This requirement applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, and methadone medication-assisted treatment for opioid addiction. Female individuals shall be evaluated by a physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C., to determine the necessity of a pregnancy test. In cases where it is determined necessary, individuals shall be provided testing services directly or be referred within 24 hours following placement.

6. Tests for Sexually Transmitted Diseases and Tuberculosis. A screening for sexually transmitted diseases, HIV, hepatitis, and tuberculosis shall be conducted. For a screening result indicating the individual is at-risk for any of these conditions, the provider shall conduct testing or make testing available through appropriate referral, in instances where a provider cannot or does not provide the testing. The individual may refuse the screening or the testing, and the provider shall document the refusal. Department of Health testing requirements can be found in rule 64D-2.004 and chapter 64D-3, F.A.C.

a. For intensive inpatient treatment, and residential treatment, tests will be conducted within the time frame specified for the physical examination. The results of both tests shall be reviewed and signed and dated by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C., and filed in the individual’s clinical record.

b. For methadone medication-assisted treatment for opioid addiction, the tests will be conducted at the time samples are taken for other laboratory tests. Positive results shall be reviewed and signed and dated by a physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C.

7. Special Medical Problems. Particular attention shall be given to individuals with special medical problems or needs. This includes referral for medical services. A record of all such referrals shall be maintained in the individual record.

8. Additional Requirements for Intensive Inpatient Treatment, and Residential Treatment. If an individual is readmitted within 90 calendar days of discharge to the same provider, a physical examination shall be conducted as prescribed by the physician. If an individual is readmitted to the same provider after 90 calendar days of the discharge date, the individual shall receive a complete physical examination.

9. Additional Requirements for Methadone Medication-Assisted Treatment for Opioid Addiction.

a. The individual’s current addiction and history of addiction shall be recorded in the individual record by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C. In any case, the record of the individual’s current substance use and history of substance use shall be reviewed, signed and dated by the physician, or in accordance with the medical protocol established in subsection 65D-30.004(7), F.A.C.

b. A physical examination shall be conducted on individuals who are placed directly into treatment from another provider unless a copy of the examination accompanies the individual and the examination was completed within the year prior to placement. In instances where a copy of the examination is not provided because of circumstances beyond the control of the referral source, the physician shall conduct a physical examination within five calendar days of placement.

(b) Psychosocial Assessment.

1. Information Required. The psychosocial assessment shall include the individual’s history as determined through an assessment of the following items:

a. Emotional or mental health;

b. Level of substance use impairment;

c. Family history, including substance use by other family members;

d. The individual’s substance use history, including age of onset, choice of drugs, patterns of use, consequences of use, and types and duration of, and responses to, prior treatment episodes;

e. Educational level, vocational status, employment history, and financial status;

f. Social history and functioning, including support network, family and peer relationships, and current living conditions;

g. Past or current sexual, psychological, or physical abuse or trauma;

h. Individual’s involvement in leisure and recreational activities;

i. Cultural influences;

j. Spiritual or values orientation;

k. Legal history and status;

l. Individual’s perception of strengths and abilities related to the potential for recovery; and

m. A clinical summary, including an analysis and interpretation of the results of the psychosocial assessment.

n. Documentation of determination of placement utilizing a validated tool used for service determination.

o. Documentation of appropriateness of level of care countersigned by the qualified professional or clinical supervisor.

2. Requirements for Components. Any psychosocial assessment that is completed within 30 calendar days prior to placement in any component identified in sub-subparagraphs a.-f. below may be accepted by the provider placing the individual. Otherwise, the psychosocial assessment shall be completed according to the following schedule:

a. For addictions receiving facilities, the psychosocial assessment shall be completed within three (3) calendar days of placement, unless clinically contraindicated;

b. For intensive inpatient treatment, the psychosocial assessment shall be completed within three (3) calendar days of placement;

c. For residential treatment level 1, the psychosocial assessment shall be completed within five (5) calendar days of placement;

d. For residential treatment levels 2, 3, 4, day or night treatment with community housing, and day or night treatment, the psychosocial assessment shall be completed within 10 calendar days of placement;

e. For intensive outpatient treatment and outpatient treatment, the psychosocial assessment shall be completed within 30 calendar days of placement; and

f. For methadone medication-assisted treatment for opioid addiction, the psychosocial assessment shall be completed within 15 calendar days of placement.

3. Psychosocial Assessment Sign-off Requirements. The psychosocial assessment shall be completed by clinical staff and signed and dated. If the psychosocial assessment was not completed initially by a qualified professional, the psychosocial assessment shall be reviewed, countersigned, and dated by a qualified professional within 10 calendar days of completion. (Inmate Substance Abuse Programs operated by or under contract with the Department of Corrections or the Department of Management Services shall conduct the review and sign-off within 30 calendar days.)

4. Psychosocial Assessment Readmission Requirements. In instances where an individual is readmitted to the same provider for services within 180 calendar days of discharge, a psychosocial assessment update shall be conducted, if clinically indicated. Information to be included in the update shall be determined by the qualified professional. A new assessment shall be completed on individuals who are readmitted for services more than 180 calendar days after discharge. In addition, the psychosocial assessment shall be updated annually for individuals who are in continuous treatment for longer than one (1) year.

5. Assessment Requirements Regarding Individuals Who Are Referred or Transferred.

a. A new psychosocial assessment does not have to be completed on individuals who are referred or transferred from one (1) provider to another or referred or transferred within the same provider if the provider meets at least one (1) of the following conditions:

(I) The provider or component initiating the referral or transfer forwards a copy of the psychosocial assessment information prior to the arrival of the individual;

(II) Individuals are referred or transferred directly from a specific level of care to a lower or higher level of care (e.g., from detoxification to residential treatment or outpatient to residential treatment) within the same provider or from one (1) provider to another; or

(III) The individual is referred or transferred directly to the same level of care (e.g., residential level 1 to residential level 1) either within the same provider or from one (1) provider to another.

b. In the case of referral or transfer from one (1) provider to another, a referral or transfer is considered direct if it was arranged by the referring or transferring provider and the individual is subsequently placed with the provider within seven (7) calendar days of discharge. This does not preclude the provider from conducting an assessment. The following are further requirements related to referrals or transfers:

(I) If the content of a forwarded psychosocial does not comply with the psychosocial requirements of this rule, the information will be updated, or a new assessment will be completed;

(II) If an individual is placed with the receiving provider later than seven (7) calendar days following discharge from the provider that initiated the referral or transfer, but within 180 calendar days, the qualified professional of the receiving provider will determine the extent of the update needed; and

(III) If an individual is placed with the receiving provider more than 180 calendar days after discharge from the provider that initiated the referral or transfer, a new psychosocial assessment must be completed.

(c) Co-occurring Mental Illness and Other Needs. The assessment process shall include the identification of individuals with mental illness and other needs. Such individual shall be accommodated directly or through referral. A record of all services provided directly or through referral shall be maintained in the individual’s clinical record.

Rulemaking Authority 397.321(5) FS. Law Implemented 397.4014, 397.410 FS. History–New 8-29-19.