Rule 5122-40-07 | Program policies and patient records.
(A) Each opioid treatment program will have written policies or procedures that include, but are not limited to, the following:
(1) Admission criteria for adolescents and adults for medication maintenance and detoxification, including at a minimum:
(a) Determination by an individual qualified to diagnose by their scope of practice that the patient is currently dependent on an opioid drug according to the current diagnostic and statistical manual for mental disorders or the international statistical classification of diseases and related health problems;
(b) A patient under eighteen years of age will have two documented unsuccessful attempts at short-term detoxification or alcohol and other drug treatment within a twelve-month period and will have written consent for maintenance from a parent or legal guardian; and,
(c) Any other federal admission requirements.
(2) Admission procedures for medication maintenance and detoxification;
(3) Procedures for providing counseling on preventing exposure to and the transmission of tuberculosis, hepatitis type B and C, and human immunodeficiency virus (HIV) disease for each patient admitted or readmitted to maintenance or detoxification treatment;
(4) Policies and procedures for the frequency of testing someone with new or increased risk factors for tuberculosis, sexually transmitted diseases, hepatitis type B and C, and HIV disease.
(5) Policy or procedure that establish ratios of primary counselors to patients that are in accordance with the requirements for counselors in rule 5122-40-09 of the Administrative Code.
(6) Policies and procedures that treatment will meet the standards of medical care for opioid treatment services established by the American society of addiction medicine, 2015 edition, or other nationally recognized standards organization selected by the director.
(7) Procedures for the ordering, delivery, receipt and storage of any medication used for medication assisted treatment;
(8) Policy or procedure for the security alarm system that includes, but is not limited to, the following:
(a) Provisions for testing the alarm system; and,
(b) Provisions for documenting the testing of the alarm system.
(9) Policy or procedure which specifies which staff will have access to the program's medication assisted treatment supply;
(10) Procedures for administering medication assisted treatment in accordance with the requirements of rule 5122-40-06 of the Administrative Code;
(11) Procedures for dispensing medication assisted treatment, including days and hours, in accordance with the requirements of rule 5122-40-06 of the Administrative Code;
(12) Policy or procedure for days and hours for non-medication dispensing program services;
(13) Policies and procedures for the involuntary termination of patients in accordance with the requirements of rule 5122-40-14 of the Administrative Code;
(14) Procedures for referring or providing prenatal services to pregnant patients in accordance with the requirements of rule 5122-40-06 of the Administrative Code;
(15) Policies and procedures for take-home doses of medication assisted treatment in accordance with the requirements of rule 5122-40-06 of the Administrative Code;
(16) Policy or procedure for urinalysis for patients in accordance with the requirements of rule 5122-40-11 of the Administrative Code;
(17) Policies and procedures for urinalysis for employees of the opioid treatment program;
(18) Procedure for cleaning the medication areas;
(19) Policies and procedures for missed medication administration appointments;
(20) Policies and procedures stating that medication assisted treatment will not be provided to a patient who is known to be currently receiving medication assisted treatment from another opioid treatment program with the exception of guest dosing patients whose need for medication maintenance has been verified by the medical director or other authorized program physician of both the opioid treatment program where the patient is currently enrolled and at the program where the patient is requesting to receive services;
(21) Policies and procedures related to disaster planning, pursuant to rule 5122-40-12 of the Administrative Code;
(22) Policies and procedures relating to a diversion control plan, pursuant to rule 5122-40-10 of the Administrative Code; and,
(23) Policies and procedures for accessing the states drug database pursuant to section 4729.75 of the Revised Code, pursuant to rule 5122-40-08 of the Administrative Code.
(24) Policies and procedures relating to permanent patient transfer, pursuant to rule 5122-40-08 of the Administrative Code.
(B) An individual client record will be maintained for each client, and contain the following:
(1) Date of each visit that the patient makes to the program;
(2) Date, time, and amount of medication administered or dispensed along with the printed name and original signature of the service provider;
(3) Medical history;
(4) Documentation of physical examination and results;
(5) Results for serological tests for hepatitis type B and C performed by the program or a copy of results when performed by another entity. The program may accept results from tests performed within the past six months;
(6) Result of a serological test for HIV performed by the program or a copy of results when performed by another entity within the past six months. The program may accept results from tests performed within the past six months;
(7) Results of a serological test for syphilis performed by the program or a copy of results when performed by another entity within the past six months. The program may accept results from tests performed within the past six months;
(8) Results of tubercular skin test or interferon gamma release assay (IGRA) blood test performed by the program or a copy of results when performed by another entity within the past six months. The program may accept results from tests performed within the past six months;
(9) Results of a urinalysis for drug determination at the time of admission and the results of each subsequent urinalysis;
(10) Assessment in accordance with Chapter 5122-29 of the Administrative Code;
(11) Individualized treatment plan in accordance with Chapter 5122-27 of the Administrative Code;
(12) Progress notes in accordance with Chapter 5122-27 of the Administrative Code;
(13) Documentation of counseling on preventing exposure to tuberculosis, hepatitis type B and C, and the transmission of human immunodeficiency virus (HIV) disease;
(14) Documentation of provision of the following when the individual has been assessed as in need of these services, either directly or through referral to adequate and reasonably accessible community resources:
(a) Vocational rehabilitation services;
(b) Employment services; and.
(c) Education services.
(15) Documentation to reflect that the program has attempted to determine whether or not the patient is enrolled in any other opioid treatment program. This documentation may be stored in either the client record or the central registry system;
(16) Documentation to reflect verification by the medical director or other authorized program physician of the need for medication assisted treatment for guest dosing patients;
(17) Information required by Chapter 5122-27 of the Administrative Code; and,
(18) Documentation of any check of the prescription drug monitoring program data pursuant to rule 5122-40-08 of the Administrative Code.
(C) Patient records will be maintained for at least seven years from the last date of administering or dispensing a controlled substance.
(D) Opioid treatment programs may substitute in-office and staff supervised cheek swabs for toxicology testing for oral fluid testing, urine screens, urine drug screens or urinalysis wherever required by rule in this chapter.
Last updated June 5, 2023 at 8:28 AM
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