This chapter establishes general licensing and operating standards for all substance abuse treatment programs in North Dakota, covering the full continuum of ASAM levels of care from outpatient through residential and inpatient settings, as well as detoxification, opioid treatment, and partial hospitalization. Operators must comply with requirements for licensure application and renewal, personnel administration, physical facilities, health and safety, infection control, client records, assessment, individual treatment planning, admission/continued stay/discharge criteria, client rights, and quality assurance. Specific provisions address programs serving adolescents, including criminal history checks for staff and clinical criteria for placing adolescents in adult programs. These general standards apply across all program types governed by Article 75-09.1.
View official sourceARTICLE 75-09.1 SUBSTANCE ABUSE TREATMENT PROGRAMS Chapter 75-09.1-01 General Standards for Substance Abuse Treatment Programs 75-09.1-02 Clinically Managed Low-Intensity Residential Care - Adult ASAM Level III.1 75-09.1-02.1 Clinically Managed Low-Intensity Residential Care - Adolescent ASAM Level lll.1 75-09.1-03 Clinically Managed High-Intensity Residential Care - Adult ASAM Level lll.5 75-09.1-03.1 Clinically Managed Medium-Intensity Residential Care - Adolescent ASAM Level lll.5 75-09.1-04 Medically Monitored Intensive Inpatient Treatment - Adult ASAM Level lll.7 75-09.1-04.1 Medically Monitored High-Intensity Inpatient Treatment - Adolescent ASAM Level lll.7 75-09.1-05 Partial Hospitalization - Day Treatment - Adult ASAM Level ll.5 75-09.1-05.1 Partial Hospitalization - Day Treatment - Adolescent ASAM Level ll.5 75-09.1-06 Intensive Outpatient Treatment - Adult ASAM Level II.1 75-09.1-06.1 Intensive Outpatient Treatment - Adolescent ASAM Level ll.1 75-09.1-07 Outpatient Services - Adult ASAM Level l 75-09.1-07.1 Outpatient Services - Adolescent ASAM Level l 75-09.1-08 Social Detoxification ASAM Level lll.2-D 75-09.1-09 DUI Seminar ASAM Level 0.5 75-09.1-10 Licensing and Treatment Standards for Opioid Treatment Programs 75-09.1-11 Substance Use Disorder Treatment Voucher System 75-09.1-12 Licensing Standards for Medication Units CHAPTER 75-09.1-01 GENERAL STANDARDS FOR SUBSTANCE ABUSE TREATMENT PROGRAMS Section 75-09.1-01-01 Definitions 75-09.1-01-02 Application for License and Notice of Address Change 75-09.1-01-03 Provisional and Unrestricted License 75-09.1-01-04 License Report Procedures 75-09.1-01-05 Program Authority and Administration 75-09.1-01-06 Information Management 75-09.1-01-07 Personnel Administration 75-09.1-01-08 Fiscal Management 75-09.1-01-09 Physical Facilities 75-09.1-01-10 Health and Safety Program 75-09.1-01-11 Infection Control 75-09.1-01-12 Transportation 75-09.1-01-13 Intake and Orientation 75-09.1-01-14 Assessment 75-09.1-01-15 Individual Treatment Plan 75-09.1-01-16 Differences in Dimensional Criteria for Adolescents and Adults 75-09.1-01-17 Criteria for Programs That Treat Adolescents and Adults 75-09.1-01-18 Admission Criteria 75-09.1-01-19 Continued Stay Criteria 75-09.1-01-20 Discharge and Transfer Criteria 75-09.1-01-21 Referral Criteria 75-09.1-01-22 Client Records 75-09.1-01-23 Client Rights 75-09.1-01-24 Quality Assurance 75-09.1-01-25 Accreditation as a Basis for Licensing 75-09.1-01-26 Sanctions 75-09.1-01-27 Appeals 1 75-09.1-01-01. Definitions. As used in chapters 75 -09.1-01, 75-09.1-02, 75-09.1-02.1, 75-09.1-03, 75-09.1-03.1, 75-09.1-04, 75-09.1-04.1, 75-09.1-05, 75-09.1-05.1, 75-09.1-06, 75-09.1-06.1, 75-09.1-07, 75-09.1-07.1, and 75-09.1-08: 1. "ASAM patient placement criteria" means the third edition, revised, of the patient placement criteria of the American society of addiction medicine. 2. "Department" means the North Dakota department of human services. 3. "DSM" means the fifth edition, of the diagnostic and statistical manual of mental disorders published by the American psychiatric association. 4. "DUI" means an offense of driving or being in actual control of a motor vehicle while under the influence of alcohol or controlled substances, or both. 5. "Program" means a person, partnership, association, corporation, or limited liability company that establishes, conducts, or maintains a substance abuse treatment program for the care of persons addicted to alcohol or other drugs. "Program" does not include a DUI seminar which is governed by chapter 75-09.1-09. 6. "Recommendation" means a violation of the rule has occurred, however, on a very limited basis. A recommendation can also be given when there is general compliance with a rule but the procedures can be strengthened. 7. "Type I condition" means a violation of the requirements of any applicable law or regulation has occurred in at least twenty-five percent of the cases reviewed. 8. "Type II condition" means habitual noncompliance with the requirements of any law or regulation including a type l condition that is still found to be occurring during subsequent visits, any illegal act, or any act that threatens the health or safety of the clients. History: Effective October 26, 2004; amended effective April 1, 2018. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-02. Application for license and notice of address change. 1. A program must submit to the department an application for a license in the form and manner prescribed by the department. 2. The department will consider an application complete when it has received all required information and documents. 3. The department may declare an application withdrawn if an applicant fails to submit all required documentation within sixty days of notification of incompleteness. 4. A new application for a license must be submitted to the department by a program upon change of ownership or level of care. 5. A program must notify the department of a change of address. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 2 75-09.1-01-03. Provisional and unrestricted license. 1. Provisional license. a. Upon approval of an application, the department may issue a provisional license for the operation of a program. b. A provisional license is in effect for the period specified in the license not to exceed one year from the date of issuance. c. Prior to changing a provisional license to an unrestricted license, the department shall conduct an onsite review to determine that the program is in compliance with the standards contained in this article. 2. Restricted license. a. A restricted license is in effect for the period specified in the license not to exceed ninety days. b. Prior to removing a restriction on a license and issuing an unrestricted license, the department shall conduct an onsite review to determine that the program is in compliance with the standards contained in this article. 3. An unrestricted license is in effect for the period specified in the license not to exceed two years. 4. A license may not be transferred and is valid only for those programs indicated on the license. 5. The department shall conduct continued license reviews for programs with unrestricted licenses on at least a biennial basis to determine continued compliance with the standards contained in this article. 6. The department may conduct scheduled or unscheduled visits at times other than routine license reviews. 7. The program must display its current license in a place that is conspicuous to the public. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-04. License report procedures. 1. Within thirty days of an onsite review of a program, the department must send a license report to the program that was reviewed. 2. A license report must contain a description of the programs and services reviewed, strengths, concerns, recommendations, and a description of any existing type l or type ll conditions. 3. A license report shall be retained by the department while the program that is the subject of the report is licensed and for at least seven years from the time the program is no longer licensed. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 3 75-09.1-01-05. Program authority and administration. 1. A program shall identify to the department an individual or entity that is responsible for the conduct of the program. 2. A program shall implement a written policy governing the operation of services including admission procedures, discharge procedures, client grievance procedures, scope of service, treatment plans, staffing patterns, outside referrals, and continued or followup treatment. 3. The program shall conform to applicable legal requirements and regulations of all governmental and legally authorized agencies under whose authority it operates, to include accessibility, affirmative action, equal employment opportunity, health and safety, and licensure. 4. A program shall be responsible for providing qualified personnel, facilities, and equipment needed to carry out the goals and objectives and meet the needs of the clients. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-06. Information management. 1. A program must collect data as prescribed by the department, including information necessary for federal and state grant statistical requirements and fiscal information such as fee structure. 2. A program must apply appropriate safeguards to protect client records regardless of whether the records are electronically or manually maintained. These safeguards must include: a. Limiting record access to authorized individuals; b. Suitably maintaining a record indexing and filing system to preserve confidentiality; c. Knowing the essential record location at all times; d. Securing and reasonably protecting records against loss, damage, and inappropriate access; and e. Protecting electronic records by routine backup. 3. A program must maintain a policy so that files are not needlessly retained or prematurely discarded. The retention of records of clients and administrative records must be guided by professional and state research, administrative, and legal requirements. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-07. Personnel administration. 1. A program shall employ sufficient and qualified staff members to meet the needs of the clients. 2. A program shall have a written policy regarding how it verifies the background, qualifications, and credentials of staff members, volunteers, and consultants, and how it acts upon the results of the information received. 3. A program shall document the nature and extent of the involvement of any individual who provides consultation or volunteer service to the program. 4 4. A program shall maintain a personnel file for each employee that contains: a. A written job description; b. The qualifications, supervisor, employees supervised, and the duties of each employee; and c. Performance evaluations dated and regularly conducted at least annually for continuing appropriateness. 5. A program shall implement a written employment policy related to nondiscrimination with regard to employment, pay, place of work, or promotion because of age, creed, disability, gender, national origin, or race. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-08. Fiscal management. 1. When fees for services are charged, a program shall have an established schedule of fees that is available in printed form and is applied equitably to all clients. 2. A program shall implement a policy that prohibits fee splitting with other programs, agencies, entities, or individuals as consideration for referral of the client to be served. 3. If a program is responsible for funds or personal possessions that belong to a client, the program shall implement a procedure for identification and accountability for those funds. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-09. Physical facilities. 1. All locations owned, rented, leased, or occupied by a program must meet standards of the state fire marshal or an equivalent code or provide a letter from the inspecting authority stating that an inspection was not done and the reason why. 2. A program shall provide suitable locations within the physical plant for such activities as interviews, treatment services, dictation, staff conferences, and psychometric testing to provide for confidentiality of client information. 3. A program shall provide adequate toilet and lavatory facilities. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-10. Health and safety program. 1. A program shall maintain health and safety policies and procedures. 2. A program shall implement a written emergency plan that addresses provisions for dealing with bomb threats, fires, medical emergencies, natural disasters, and power failures. 3. A program shall make readily available first -aid facilities, equipment, and supplies. A program shall have: 5 a. At least one staff member certified in basic first aid and in basic cardiac life support. At least one employee certified in cardiopulmonary resuscitation must be present at the program during all hours of program operations. The number of other certified individuals present must be based on the needs of the clients and the type of services provided; and b. A program must implement a written plan to assist a client in receiving additional care beyond first aid when it is needed. An outline of the plan must be posted where first -aid supplies are kept and at other appropriate places in the physical plant. 4. Designated staff members shall be responsible for the safety of clients and personnel under their supervision in the event of emergency or emergency drill. 5. A program shall implement a written plan for reporting all incidents, including serious illnesses, injuries, and alleged cases of abuse or neglect. 6. A program shall implement a written policy that addresses the use of smoking products. The policy must address the needs of the clients, personnel, visitors, and it must comply with local, state, and federal laws. 7. A program shall implement a written policy that is in conformance with applicable legal requirements to govern the safe administration, handling, storage, and disposal of medications. A program must document appropriate training of its employees according to state laws. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-11. Infection control. 1. A program shall implement a written infection control policy that complies with all applicable laws and regulations. The program must review this written policy at least annually and at any other times as necessary. The policy must provide screening or referral procedures and must include a documented verbal assessment of high -risk behaviors for tuberculosis, hepatitis, HIV, and other blood-borne and sexually transmitted diseases. 2. A program shall implement a practical system developed for reporting, evaluating, and maintaining records of infections among clients. 3. A program shall implement a written plan for the instruction of new employees in the importance of infection control and personal hygiene and their responsibility in the infection control program. 4. A program shall take universal precautions in the handling of all bodily fluids and implement written policies for the handling of bodily fluids. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-12. Transportation. If a program provides client transportation services, whether by volunteers or by contract, the program shall provide evidence to the department that the program maintains state minimum liability insurance coverage and that any employee who provides transportation has a current and appropriate driver's license. 6 History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-13. Intake and orientation. 1. A program shall implement written criteria for client admission for each of the program's levels of care based on the DSM and the ASAM patient placement criteria and policies for client admission. 2. A program shall implement a written policy for orientation of the client and the family. 3. A program shall explain the rights and responsibilities of persons served and grievance and appeal procedures. A program shall post in a place that is conspicuous to the public these rights and responsibilities. 4. A program shall implement a written policy regarding provision of services for clients who do not have the ability to pay. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-14. Assessment. 1. When conducting an assessment, a program shall administer instruments or conduct clinical interviews or both sufficient to gather enough information to substantiate or rule out a client's diagnosis. 2. An assessment must include adequate assessment in at least each of the following areas: withdrawal potential; medical conditions and complications; psychiatric, including emotional, behavioral, and cognitive functioning and the presence of co-occurring mental health problems; employment; alcohol, tobacco, and other drug use; legal; family and social; readiness to change; relapse, continued use, and continued problem potential; and recovery environment. 3. When clinically appropriate, previous diagnostic, medical, treatment, and training reports that impact the development of an individual must be: a. Requested from appropriate current or previous providers and referral sources with signed, informed consent to release of information forms in compliance with applicable laws and regulations; and b. Integrated into the assessment process. 4. A program shall provide requested information within a reasonable time period when the request is accompanied by an appropriate consent to release of information. 5. A program's report from the assessment process must clearly describe the diagnostic impressions based on a five-axis assessment of the DSM and recommendations for treatment based on the ASAM patient placement criteria. 6. Based on the information gathered in the assessment, a program's report should identify and prioritize problems by severity, which should then be addressed in the individual treatment plan with the involvement of the client. 7. A program shall keep progress notes that reflect the client's progress or lack of progress in measurable and behavioral language associated with treatment plan objectives. 7 History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-15. Individual treatment plan. 1. A program shall implement policies that ensure the services provided to each client are coordinated and integrated and address goals that reflect the client's informed choice. 2. A program shall develop, with each client's participation, a comprehensive, coordinated, individualized plan based on referral and assessment information about the client's strengths, abilities, needs, functional deficits, and preferences. 3. A program shall develop and document an individual treatment plan that is as comprehensive as possible given the time in treatment and the client's condition. The individual treatment plan shall be developed according to the following schedule: a. By the end of the first day for a client in a social detoxification program; b. By the end of the third session for a client receiving outpatient services or intensive outpatient treatment; and c. By the end of the fifth working day for a client receiving day treatment, inpatient, or low-intensity and high-intensity residential treatment. 4. A program shall implement a written policy that specifies instances in which signed, informed consent for services must be obtained and retained. The policy must be guided by professional and legal requirements. 5. A program must regularly analyze with the active involvement of the client the client's progress toward the accomplishment of goals and modify goals and services as a result of any occurrence that is likely to impact the client's treatment progress. A program must perform such an analysis no less often than: a. Once every two months or every eight sessions, whichever comes first, for a client receiving outpatient services; b. Once a month for a client receiving low-intensity residential treatment; c. Once every two weeks for a client receiving intensive outpatient treatment; d. Once each week for a client receiving high-intensity residential, inpatient, or partial hospitalization or day treatment; and e. Once during the first six months and annually thereafter for a client receiving chronic care and maintenance services. 6. Counseling or assessment regarding an individual's use or abuse of alcohol or a controlled substance must be provided by a licensed addiction counselor as required by North Dakota Century Code chapter 43-45. The provision of case management and educational services do not need to be performed by a licensed addiction counselor. A licensed addiction counselor must be present in all team meetings at which level of care and treatment planning decisions are made regarding a client receiving or referred for substance abuse treatment services. 7. Services essential to the attainment of a client's goals and objectives must be provided or it must be documented that attempts were made to provide such services either through staff members or through formal affiliation or consultation arrangements with or referral to appropriate agencies or individuals. 8 History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-16. Differences in dimensional criteria for adolescents and adults. 1. If a program plans to admit an individual age seventeen or younger, the program shall implement a written policy regarding how to determine when it is appropriate to place an adolescent in an adult program. The policy must address the safety and supervision of clients in that program. The decision to determine whether a person seventeen years of age or younger is appropriately served in an adult rather than an adolescent program must be based on clinical judgment and other factors such as: a. History of sexual acting out; b. History of violence; c. History of running away; d. Living status such as whether the adolescent is living independently or with parents; e. School status; f. Employment status; g. Marital status; h. Ability to act responsibly; i. Level of emotional maturity; j. Level of cognitive development; k. Level of parental or family support; and l. Current mix of population in the adult milieu. 2. A program shall document in the client record the clinical justification for its decision to treat an individual age seventeen years or younger in an adult program. 3. A program shall maintain a list of all potential adolescent admissions with documentation of those admitted to the program and those denied admission to the adult program due to failure to meet the requirements of this section. 4. The department may issue the designation of "adolescent -adult combined program" to the license of any program that intends to serve, in an adult program, adolescents who screen according to the requirements of this section. In order to receive such a designation, the program must be in compliance with the other requirements of this article. The designation may be added to any type of license described in this article with the exception of medically monitored inpatient licenses. History: Effective October 26, 2004; amended effective July 19, 2005. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-17. Criteria for programs that treat adolescents and adults. 1. A program shall secure a criminal history record investigation for any employee who works with adolescents. 9 a. A program shall secure from any employee who may have any contact with an adolescent treated by the program identifying information that is appropriate to accomplish a criminal history record investigation. b. A program providing services to adolescents that held a license in good standing before the effective date of this section shall complete a criminal history record investigation check for all existing employees within thirty days of the effective date of this section. c. A program may not allow an employee to begin work until the criminal history record investigation is complete and it shows fitness to work with adolescents. A program may not employ, in any capacity that involves or permits contact between the employee and any adolescent treated by the program, an individual who is known to have been found guilty of, pled guilty to, or pled no contest to: (1) An offense described in North Dakota Century Code chapter 12.1 -16, homicide; 12.1-17, assaults - threats - coercion - harassment; or 12.1 -18, kidnapping; North Dakota Century Code section 12.1-20-03, gross sexual imposition; 12.1-20-04, sexual imposition; 12.1-20-05, corruption or solicitation of minors; 12.1-20-05.1, luring minors by computer; 12.1-20-06, sexual abuse of wards; 12.1-20-06.1, sexual exploitation by therapist; 12.1-20-07, sexual assault; 12.1-22-01, robbery; or 12.1-22-02, burglary, if a class B felony under subdivision b of subsection 2 of that section; North Dakota Century Code chapter 12.1 -27.2, sexual performances by children; or North Dakota Century Code section 12.1 -29-01, promoting prostitution; 12.1-29-02, facilitating prostitution; or 12.1 -31-05, child procurement; or an offense under the laws of another jurisdiction which requires proof of substantially similar elements as required for conviction under any of the enumerated North Dakota statutes; or (2) An offense, other than an offense identified in paragraph 1, if the department determines that the individual has not been sufficiently rehabilitated or the offense has a direct bearing on the program's ability to safely serve adolescents treated there. The department will not consider a claim that the individual has been sufficiently rehabilitated until any term of probation, parole, or other form of community corrections or imprisonment, without subsequent charge or conviction, has elapsed. An offender's completion of a period of five years after final discharge or release from any term of probation, parole, or other form of community corrections or imprisonment, without subsequent conviction, is prima facie evidence of sufficient rehabilitation. 2. A program providing services to adolescents must employ staff that is knowledgeable about adolescent development or have experience in working with and engaging adolescents. 3. A program shall provide treatment to meet the level of cognitive development and other needs of an adolescent and must address the adolescent experience, including cognitive, emotional, physical, social, and moral development, in addition to involvement with alcohol and other drugs. 4. A program shall make every reasonable attempt to engage an adolescent's family members or guardian in the adolescent's assessment, treatment, and continuing care. 5. A program shall assure that all interactions between adults and adolescents are supervised where adults receive treatment at a program that also provides an adolescent-specific program. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 10 Law Implemented: NDCC 50-31 75-09.1-01-18. Admission criteria. A program shall not admit a client into a substance abuse treatment program unless the client: 1. Meets diagnostic criteria for a substance use disorder as described in the DSM; and 2. Meets specifications in each of the ASAM dimensions required for the recommended level of care. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-19. Continued stay criteria. For a client to remain in the current level of care placement, a program must document that the client: 1. Is making progress but has not yet achieved the goals articulated in the individualized treatment plan and continued treatment at the present level of care is necessary to permit the client to continue to work toward treatment goals. 2. Is not yet making progress but has the capacity to resolve problems and is actively working toward the goals articulated in the individual treatment plan. 3. New problems have been identified that are appropriately treated at the present level of care that is the least intensive in which these problems can be addressed effectively. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-20. Discharge and transfer criteria. Before a program may transfer or discharge a client, the client must have: 1. Achieved the goals articulated in the client's individualized treatment plan and resolved the problems that justified admission to the present level of care with progress evaluated and a determination has been made that the client is ready for a less intensive level of care or independent living. 2. Been unable to resolve the problems that justified admission to the present level of care despite amendments to the treatment plan and no further progress is likely indicating the need for another level of care or type of service. 3. Demonstrated a lack of capacity to resolve problems indicating the need for another level of care or type of service. 4. Experienced an intensification of problems or has developed new problems and can be treated effectively only at a more intensive level of care. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 11 75-09.1-01-21. Referral criteria. 1. A program shall implement a written policy for referral and recommendations for services not available through the program. All referrals and recommendations must be made part of the treatment or discharge plan. 2. A program must implement a written policy that verifies appropriate referral during and after treatment. 3. A program must secure the written consent of the client or a client's legal representative before releasing any confidential information about that client and the release of information must conform to the following: a. Any information released must be limited to that necessary for the individual or agency requesting the information or for the provider to whom the client is referred to address the purpose of the referral; b. A program must stamp or write on the records that are being released that any further disclosure of information is prohibited unless it is authorized by the client or the client's legal representative; c. A program's consent to release of information form must conform to applicable laws and regulations and must identify: (1) The information to be released; (2) The form in which the information is to be released such as written, verbal, audio, video, or electronic; (3) To whom the information is to be released; (4) The purpose of the information to be released; (5) The name of the client and the client's date of birth; (6) The date on which the consent to release of information is signed; (7) The length of time, event, or condition for which the consent to release of information is authorized or the event or condition upon which the consent may be withdrawn; and (8) The signature of the client or legal representative; and d. A program shall give to the client or client's legal representative a copy of the signed consent to release of information. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-22. Client records. 1. A program shall prepare and maintain a single record for each client admitted to the program so as to communicate the appropriate case information. This information must be in a form that is clear, concise, complete, legible, and current. 2. A program shall implement a written policy addressing the process by which a client may gain access to the client's own record. 12 3. If duplicates of information or reports from the single record of a client exist or if working materials are maintained, such material must: a. Not be a substitute for the single record; b. Be secondary to the recording of information with the single record of the client receiving first priority; and c. Record information of value to the specific service, such as daily attendance, raw scores of tests, and similar data. 4. A program must apply appropriate safeguards to protect active and closed confidential written, electronic, and audiovisual records and to minimize the possibility of loss or destruction in the following manner: a. The information in active and closed records must be organized in a systematic fashion. Manual systems must provide for affixing active records to record jackets; b. The location of the records of clients and the nature of the information contained therein must be controlled from a central location; c. A program employee must be responsible for the control of records of clients and for the implementation of the policies pertaining to records of clients; d. Access to records of clients and electronically generated documents must be limited to the members of the professional staff who are providing or supervising direct services to the client and such other individuals as may be administratively authorized; e. The program must maintain an indexing and filing system for all manual and electronic records of clients; f. The program must secure records and take reasonable steps to protect the records against fire, water damage, and other hazards; g. The program must follow routine procedure for backup of data files for electronic systems; and h. The program must implement a policy that defines file access control procedures. 5. Client records must include: a. Identification data; b. The name and address of the legal representative, conservator, guardian, and representative payee of the client; c. Pertinent history, a diagnostic assessment on all five axes of the DSM, a six -dimension assessment of the current version of the ASAM patient placement criteria, disability, presenting need, functional limitation, client strengths, and desired outcomes and expectations; d. Prescribed medications; e. Relevant medical information; f. Reports of assessment and individual treatment planning; g. Signed and dated progress notes describing in measurable and behavioral terms the client's progress toward the attainment of the client's treatment plan objectives; 13 h. Reports from referring sources; i. Reports of service referrals; j. Reports from outside consultants; k. Designation of the case manager, licensed addiction counselor, and other staff for the client; l. Evidence of the direct involvement of the client in the decisionmaking process related to the client's program; m. Reports of team conferences; n. Reports of family conferences; o. The individual plan of the client, including the overall plan and the plans for specific services and signature of the client or other documentation of the client's involvement in the plan; p. References to audiovisual records; q. Correspondence pertinent to the client; r. Signed and dated release forms; s. Transfer summary describing in measurable and behavioral terms a client's move from one level of care to another; t. Discharge summary describing in measurable and behavioral terms the client's progress and attainment of treatment plan goals and criteria for discharge. When the client is transferred, the discharge summary must include a discharge plan which identifies the treatment goals not yet achieved as well as any problems that have been deferred for treatment by a subsequent provider; and u. If admission, ongoing care, or discharge criteria as described by the department have not been met, the provider must document the grounds for placement, ongoing care, or discharge decisions. 6. A program shall implement a written policy that specifies time frames for entries into the records of a client, such as clinical information, critical incidents or interactions, progress notes, and discharge summaries. A program must enter progress notes into client records according to the following schedule: a. Shift entries for inpatient clients; b. Daily entries for clients in day treatment; c. Weekly entries for intensive outpatient clients; d. Weekly entries for clients in outpatient services seen once or more a week but monthly for those clients seen less than once a week; e. Weekly entries for clients in clinically managed high-intensity residential care; and f. Monthly for clients in clinically managed low-intensity residential care. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 14 Law Implemented: NDCC 50-31 75-09.1-01-23. Client rights. 1. A program must assure the right of each client to: a. Be treated with respect and dignity; b. Be treated without discrimination based on physical or mental disability; c. Be treated without regard to race, creed, national origin, sex, or sexual preference; d. Have all information handled confidentially in accord with applicable laws, regulations, and standards; e. Receive notice of federal confidentiality requirements; f. Not be subject to physical, emotional, or sexual abuse or harassment by employees or another client; g. Have services for male or female clients reflecting the special needs of each gender and to be provided equivalent, clearly defined, and well -supervised sleeping quarters and bath accommodations for male and female clients; h. Be provided a reasonable opportunity to practice the religion of the client's choice insofar as the practice does not interfere with the rights of other clients or the treatment program; i. Have the right to be excused from any religious practice; j. Have access to an established client grievance procedure; and k. Be informed of client rights in a language the client understands. 2. A program shall protect the fundamental human, civil, constitutional, and statutory rights of each client. 3. A program shall implement a written policy that describes the rights of clients and the means by which these rights are protected and exercised. 4. As appropriate, the client, the client's family, or the client's legal guardian shall be informed of the client's status if authorized by a client who is fourteen years of age or older. 5. A program shall evaluate for appropriateness any restrictions placed on the rights of individual clients. The program shall document in the client's clinical record the clinical rationale for such restrictions. 6. A program shall implement a written policy stating the form and manner in which a client may file a grievance or an appeal of a program decision. The procedure must be written in language that is understandable to the client and must be provided to the client in a timely manner. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 15 75-09.1-01-24. Quality assurance. 1. A program shall implement an established written system that provides for internal, professional review of the quality and appropriateness of the program of services for the client. 2. A program shall implement a written quality assurance plan and designate an employee to coordinate that plan. 3. A program shall implement a written policy that provides that peer review must occur at least quarterly and must involve a representative sampling of clients served. The review must be conducted irrespective of sources of funding for the clients and the documented results of the review must: a. Produce a documented list of areas needing improvement and actions taken; b. Be integrated into the individual planning, plan evaluation, and program management activities for the client; c. Be administratively used, in conjunction with results of consumer satisfaction surveys, in program evaluation activities, and in organizational planning; and d. Be reviewed at least annually by the program's administration. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-25. Accreditation as a basis for licensing. 1. The department shall issue a license to a program that has a current accreditation of a nationally recognized body that reviews and certifies providers of drug and alcohol services. 2. When applying for licensure or renewal licensure, a program must submit to the department proof of accreditation or deemed status in the form of the accreditation agency's most recent review and certification. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-26. Sanctions. 1. The department may immediately revoke a program's license upon a finding of a type II condition. 2. A program must submit to the department a plan of corrective action within thirty days of a licensure visit when a type I or type II condition has been found. A program will be allowed thirty days to submit to the department a plan of corrective action. A program will be allowed sixty days after the plan is submitted to implement the plan and satisfy a type I condition. 3. The department may conduct another onsite review prior to issuing a license after a program has developed a plan of corrective action of any condition. 4. If the program does not satisfy a condition or develop a plan to satisfy the cited condition within the time frames allowed, the department shall impose a ninety -nine-day suspension of the program's license. At the end of the ninety -nine-day suspension, if the cited condition has been corrected, the department may issue a one -year provisional license to the program. If 16 the program has not corrected the condition, the department shall revoke the provider's license immediately. 5. A program which has had its license revoked is prohibited from submitting a new application to the department for consideration for a license for any program during the three hundred sixty-five days following a license revocation for any type I or type II condition. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 75-09.1-01-27. Appeals. An applicant for or a holder of a license may appeal a decision to deny, suspend, or revoke a license by filing a written appeal with the department within thirty days of written notice of such a decision. Upon receipt of a timely appeal, an administrative hearing must be conducted in the manner provided in chapter 75-01-03. History: Effective October 26, 2004. General Authority: NDCC 50-06-16, 50-31 Law Implemented: NDCC 50-31 17