Download Substance Use Disorder Treatment Provider Manual

Substance Use Disorder
Treatment Provider
Manual
September 2015
0
Substance Use Disorder Treatment Provider Manual
This page intentionally left blank.
1
Contents
SUBSTANCE USE DISORDER TREATMENT PROVIDER MANUAL
INTRODUCTION ............................................................................................................................ 6
SFHN PHILOSOPHY OF CARE ................................................................................................. 6
SUBSTANCE USE DISORDER TREATMENT SERVICES PROGRAM
OVERSIGHT..................................................................................................................................... 6
Substance Use Disorder Treatment Provider Manual
DHCS VOLUNTARY TREATMENT CERTIFICATION & DMC CERTIFICATION 6
NEW TITLE 22: DRUG MEDI-CAL PROGRAM INTEGRITY REGULATIONS....... 7
AFFORDABLE CARE ACT OF 2010 AND DRUG MEDI-CAL CERTIFICATION .... 8
DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM WAIVER & SFHN-BHS
REQUIREMENTS ........................................................................................................................... 8
MODALITIES COVERED BY PROVIDER MANUAL ........................................................ 9
ROLE OF THE MEDICAL DIRECTOR................................................................................... 9
THE SUD TREATMENT PROCESS ........................................................................................ 10
Client Engagement ...................................................................................................................................... 10
Key SUD Intake, Admission and Treatment Process Milestones ............................................................... 11
Intake, Assessment and Admission Requirements ...................................................................................... 12
Physical Examinations .....................................................................................................................................12
Naltrexone Treatment Admission Requirements .............................................................................................13
Narcotic Treatment Program Admission Requirements ...................................................................................13
Perinatal Treatment Admission Requirements .................................................................................................14
Non-DMC Residential Treatment Admission Requirements ...........................................................................14
Initial Treatment Plan ................................................................................................................................. 14
Updated Treatment Plans ............................................................................................................................ 15
Non-DMC Residential Updated Treatment Plan Requirements .......................................................................16
2
Client Contacts ............................................................................................................................................ 16
Table of Client Contact Requirements ........................................................................................................ 18
Day Care Habilitative .......................................................................................................................................18
Collateral Services............................................................................................................................................19
Individual Counseling ..................................................................................................................................... 19
Crisis Intervention Counseling ........................................................................................................................ 19
Progress Notes ................................................................................................................................................. 19
Table of Progress Note Timelines ................................................................................................................... 20
Day Care Habilitative ...................................................................................................................................... 20
Continuing Services ..................................................................................................................................... 20
Discharge Plan ............................................................................................................................................. 21
Discharge Summary ........................................................................................................................................ 22
AVATAR AND CALOMS TREATMENT DATA ENTRY REQUIREMENTS ........... 22
CLIENT RECORD AND RETENTION REQUIREMENTS ............................................. 23
BILLING .......................................................................................................................................... 24
SFHN Services Code Project ....................................................................................................................... 24
DMC Multiple Same Day Services .............................................................................................................. 24
DMC Client Share of Cost........................................................................................................................... 25
Good Cause Codes ....................................................................................................................................... 25
PROGRAM COMPLIANCE ...................................................................................................... 25
GLOSSARY OF TERMS ............................................................................................................. 27
ABOUT THE CONTRIBUTORS .............................................................................................. 32
APPENDIX A – SFHN-BHS PHILOSOPHY OF CARE ..................................................... 34
Substance Use Disorder Treatment Provider Manual
CLIENT FAIR HEARING RIGHTS ........................................................................................ 22
APPENDIX B – DPH DRUG MEDI-CAL CERTIFICATION REQUIREMENT
CHECKLIST................................................................................................................................... 38
APPENDIX C – DHCS SUBSTANCE USE DISORDER MODALITY MATRIX ........ 39
APPENDIX D – SUBSTANCE USE DISORDER TREATMENT SERVICES BY
MODALITY .................................................................................................................................... 41
Outpatient Drug Free Treatment ................................................................................................................ 41
Day Care Habilitative .................................................................................................................................. 41
3
Narcotic Treatment Program ...................................................................................................................... 41
Naltrexone Treatment ................................................................................................................................. 42
Residentially Based Substance Use Disorder Treatment ............................................................................ 42
APPENDIX E - INDIVIDUAL CLIENT RECORD DATA SET LIST............................. 43
Substance Use Disorder Treatment Provider Manual
APPENDIX F – SAMPLE COMPLIANCE AUDIT TOOL ................................................ 45
4
Substance Use Disorder Treatment Provider Manual
This page intentionally left blank.
5
Substance Use Disorder Treatment Provider Manual Introduction
The SFHN Substance Use Disorder (SUD) Treatment Provider Manual (“Provider Manual”)
offers user friendly guidance to all City and County of San Francisco contracted and civil
service SUD treatment providers, including Drug Medi-Cal (DMC) certified providers, in
complying with State and San Francisco Health Network – Behavioral Health Services
(SFHN-BHS) SUD treatment requirements and standards. The Provider Manual reflects the
best possible quality client care standards and seeks to prevent program deficiencies that can
lead to the assessment of recoupments. It has been developed in partnership with SUD
treatment providers in the spirit of collaboration and transparency.
Substance Use Disorder Treatment Provider Manual
SFHN Philosophy of Care
6
The SFHN-BHS supports a philosophy of care that embraces the “Quadruple Aim” approach
to optimizing health care system performance by improving the patient experience of care
(including quality and satisfaction), improving the health of populations, reducing the per
capita cost of health care, and striving for workforce excellence. Treatment is delivered
through the lens of cultural humility and using a Wellness and Recovery Model that is
infused with hope and a belief that all clients can achieve their life goals (Appendix A).
Consistent with the philosophy of care for the SFHN-BHS, substance use disorder treatment
services reflect harm reduction, a public health philosophy that promotes reducing the
physical, social, emotional, and economic harm associated with drug and alcohol use, along
with other harmful behaviors on individuals and their community. Harm reduction is free of
judgment or blame and actively engages clients in setting their own treatment goals and their
recovery. Please visit Harm Reduction Policy and Guiding Principles.
Substance Use Disorder Treatment Services Program Oversight
The Department of Health Care Services (DHCS) is responsible for administering SUD
treatment in California (DHCS Substance Use Disorder Services). The San Francisco
Department of Public Health SFHN-BHS contracts with DHCS to fund local SUD treatment
services. As part of the contract with DHCS, SFHN-BHS ensures that state SUD treatment
requirements and standards are met by maintaining fiscal management systems, monitoring
provider billing, conducting compliance site visits, processing claims for reimbursement, and
offering training and technical assistance to SUD treatment providers.
DHCS Voluntary Treatment Certification & DMC Certification
The Department of Health Care Services offers voluntary facility certification to programs
providing outpatient, intensive outpatient, and nonresidential detoxification treatment. This
voluntary certification is granted to programs that exceed minimum levels of service quality
and are in substantial compliance with State program standards, specifically the Alcohol
and/or Other Drug Certification Standards.
In addition, DHCS provides Drug Medi-Cal Certification to SUD treatment providers
that meet requirements found under Title 22 of the California Code of Regulations (CCR): 1)
Section 51431.1 – Program Administration; 2) Section 51490.1 – Claim Submissions
Requirements; and 3) Section 51561.1 – Reimbursement Rates and Requirements.
Title 22 refers and ties to Title 9 of the CCR which governs requirements for Narcotic
Treatment Programs. Providers are encouraged to learn more about state licensing and
certification requirements by visiting the DHCS website.
New Title 22: Drug Medi-Cal Program Integrity Regulations
New DMC regulations cover documentation requirements for DHCS reviews, clarify existing
regulations, and make programmatic changes to DMC regulations that impact individual and
group counseling sessions, physical examination requirements, physician review
requirements, client treatment plans, progress notes, and discharge planning. Following is a
summary of DMC regulatory changes:














Strengthening physical examination requirements during the intake process (physical
examination waivers are no longer allowed);
Requiring licensed physicians to review client personal, medical and substance use
histories during the intake process;
Allowing therapists, physician assistants, or nurse practitioners to evaluate clients to
diagnose whether a client has a DSM 5 Substance Use Disorder, subject to a
physician’s review and written approval;
Requiring face-to-face contact occur in person at a certified facility (telephone contacts,
home visits, and hospital visits are not considered face-to-face);
Prohibiting minors from participating in group counseling sessions with adults except at
certified school sites;
Establishing a group counseling size of two to twelve participants (with at least one
Medi-Cal eligible participant) for Outpatient Drug-Free, Narcotic Treatment Program,
and Day Care Habilitative services;
Revising requirements for group counseling session sign-in sheets;
Requiring individual and group counseling sessions be conducted in confidential
settings;
Requiring clients, counselors, therapists and physicians to type or legibly print their
name and date treatment plans, progress notes and discharge plans;
Requiring client treatment plans to include client diagnoses and goals related to
physical exams and medical illnesses;
Requiring clients to participant in the preparation and review of their treatment plans
and sign their treatment plans;
Specifying when counselors and therapists must prepare progress notes;
Requiring a licensed physician to review additional documents in determining whether
continued services are medically necessary for a client; and
Establishing a requirement for providers to prepare client discharge plans including
plan content and documentation requirements.
Substance Use Disorder Treatment Provider Manual
As a result of the findings of targeted field reviews of DMC providers suspected of
committing fraud and abuse within the State, the DHCS has promulgated new regulations
under CCR, Title 22, Section 51341.1 in the form of a California State Plan Amendment.
The DHCS DMC Program Integrity regulations address abusive and fraudulent practices,
promote treatment practices that are based sound medical practice, and provide DHCS with
increased regulatory authority to ensure both program integrity and that providers meet
performance expectations. The Provider Manual incorporates the DHCS DMC Program
Integrity Regulations which have been approved by the federal government and became
effective July 1, 2015.
7
Affordable Care Act of 2010 and Drug Medi-Cal Certification
Currently, the Substance Abuse Prevention and Treatment (SAPT) Block Grant is a primary
source of support for SUD treatment programs in San Francisco. SAPT funding
requirements do not allow grant funds to be used for services that have become an
entitlement under Medicaid (Medi-Cal in California).
Substance Use Disorder Treatment Provider Manual
Under the federal Affordable Care Act (ACA) of 2010, drug rehabilitation is a new essential
benefit (entitlement) that must be provided by health insurance sold on health insurance
exchanges or provided by Medicaid to certain newly eligible adults. In other words,
substance use disorder treatment services have become an entitlement under Medi-Cal.
While the ACA offers an important new opportunity to leverage Medi-Cal funding to support
increased local access to SUD treatment, it also will significantly impact local SUD treatment
programs funded through SAPT.
8
Given the expected increase in the number of individuals who will be eligible to receive SUD
treatment under the ACA, the SFHN-BHS will encourage SUD treatment providers to begin the
process of obtaining DMC certification. It is expected that in the future, SFHN-BHS will require
all funded SUD treatment providers to be DMC certified to continue to receive SFHN-BHS
funding for SUD treatment services. The SFHN-BHS is committed to supporting SUD treatment
providers in obtaining DMC certification. A DMC certification requirement checklist has been
developed as a guide (Appendix B). For more information regarding DMC certification, please
contact the DPH Business Contract Compliance Office at (415) 255-3400.
Drug Medi-Cal Organized Delivery System Waiver & SFHN-BHS
Requirements
The “Drug Medi-Cal Organized Delivery System (DMC-ODS)” is a State Pilot to test a new
paradigm for the organized delivery of health care services for Medicaid eligible individuals
with substance use disorders. The DMC-ODS will demonstrate how organized substance use
disorder care increases the success of DMC beneficiaries while decreasing other system
health care costs. Critical elements of the DMC-ODS Pilot include providing a continuum of
care modeled after the American Society of Addiction Medicine (ASAM) Criteria for
substance use disorder treatment services, increased local control and accountability, greater
administrative oversight, new utilization controls to improve care and efficient use of
resources, evidence-based practices in substance abuse treatment, and increased coordination
with other systems of care. The DMC-ODS Pilot approach is expected to provide Medi-Cal
clients with improved access to care and to support the level of system interaction needed to
achieve sustainable recovery. The City and County of San Francisco will participate as a
Phase I county under the DMC-ODS, effectively beginning in Fiscal Year 2015-16.
Not only do DMC treatment standards and requirements reflect good clinical practice, but also
they offer San Francisco the opportunity to improve access to high quality care under the DMCODS Pilot program. In an effort to encourage SFHN-BHS funded SUD treatment providers to
obtain DMC certification and align SFHN-BHS SUD treatment requirements under the DMCODS Pilot, beginning in Fiscal Year 2015-16 and beyond, all SUD treatment providers will be
required to adhere to DMC treatment standards and requirements regardless of their DMC
certification status, unless otherwise stated in the Provider Manual.
Modalities Covered by Provider Manual
The SFHN-BHS Provider Manual covers the following SUD treatment modalities1:





Outpatient Drug Free (ODF)
Narcotic Treatment Program (NTP)
Naltrexone Treatment
Day Care Habilitative Services (see note below re: Intensive Outpatient Services)2
Residentially Based Substance Use Disorder Services (incorporates Perinatal
Residential Substance Use Disorder Services)
Role of the Medical Director
While SUD treatment providers may have more than one physician or medical director on
staff, the medical director has medical responsibility for all clients and must be available on a
regularly scheduled basis. Duties of a medical director may vary, but at a minimum, DMC
certified treatment provider medical directors must be responsible for:
 Establishing, reviewing, maintaining medical policies and standards;
 Ensuring the quality of medical services provided to all clients;
 Ensuring that at least one physician providing services for the provider has admitting
privileges to a general acute hospital; and
 Ensuring that a physician has assumed medical responsibility for all clients treated by
the provider.
Medical Necessity
All SUD treatment providers must ensure that treatment services are medically necessary.
Medical necessity is established when a client is diagnosed with a substance use disorder
based on the Diagnostic and Statistical Manual (DSM) of Mental Health Disorders 5, and the
DSM diagnosis is documented in the individual client record within 30 calendar days of the
client’s admission to treatment date, no sooner than 5 months and no later than 6 months
after a client’s admission to treatment, or the completion of the most recent justification for
services. DSM codes that may be used include mental, emotional, psychological, behavioral
and substance use codes. Medical necessity also may include a physical examination and
laboratory testing by staff lawfully authorized to provide such services.
Substance Use Disorder Treatment Provider Manual
While intake/assessment and treatment plans are standardized across SUD treatment
modalities, there are some differences in the type and frequency of required client services by
modality. Please see Appendix C & Appendix D for modality service descriptions and a
DHCS matrix depicting substance use disorder services by treatment modality.
Physicians, therapists, physician assistants, or nurse practitioners acting within the scope of
their respective practices may evaluate whether a client has a substance use disorder at
intake. Where a therapist, physician assistant or nurse practitioner performs a client
diagnosis, a physician must review each client’s diagnosis and document his or her approval
of the diagnosis by signing legibly and dating the client’s treatment plan.
9
1
The DHCS has proposed medically necessary Intensive Inpatient Detoxification as a new substance use disorder treatment service for the
general treatment population. The DPH DMC Provider Manual will be revised to cover this new service when additional information is
available from DHCS regarding specific regulatory requirements.
2
The DMC-ODS Organized Delivery Pilot requires counties to provide Intensive Outpatient Services which are similar in scope to day care
habilitative services.
For all DMC certified providers, medical necessity must be established by the Medical
Director who must be a physician licensed by the Medical Board of California or the
Osteopathic Medical Board of California. Throughout the treatment process, client records
must document and demonstrate that a physician directed the provision of treatment
including the establishment of medical necessity at admission and for continuing services,
the development and review of client treatment plans, and medical consultation and
evaluation.
Substance Use Disorder Treatment Provider Manual
The SUD Treatment Process
10
The SUD treatment process reflects a logical approach that can be applied to solving
challenges in any area. Solving a challenge begins with the preliminary identification of the
general nature of the challenge, followed by a more detailed determination of the specifics of
the challenge. For substance use disorder treatment providers, this preliminary step is the
intake process of admission (identifying the challenges faced by a client and establishing
how a provider can help) and assessment (determining the various issues that make up the
challenge).
As a next step in the process, a treatment plan is developed in partnership with clients to
address issues identified during the assessment process, followed by the implementation of
the treatment plan (clients receiving treatment and referrals). The treatment plan is
continually updated and changed to reflect any changes in problems or a new treatment
focus. When SUD treatment services are completed and a program determines that the client
has made sufficient progress to be discharged, providers discharge a client, prepare a
discharge plan, and close the client record.
If any of the SUD treatment process steps are not completed, the chances for positive client and
program compliance outcomes are greatly reduced. Please see the table on the next page which
summarizes major treatment milestones.
Client Engagement
All SUD provider must have a treatment planning process that meaningfully engages clients
in the development of initial treatment plans and any updates to the treatment plan. Each
client must review, approve, type or legibly print their name, sign and date his or her
treatment plans and indicate whether he or she was involved in the plan’s development. If a
client refuses to sign his or her treatment plan, providers must indicate the reason for refusal
and document strategies that will be taken to engage the client in treatment.



Intake and Admission




Initial Treatment Plan


Treatment Plan
Update(s)



Medical Necessity for
Continued Services


Discharge Plan


Discharge Summary
Must complete a personal, medical, and substance use history for each
client that evaluates the cause or nature of each client’s mental,
emotional, psychological, behavioral and substance use disorders.
Must complete DPH Health Questionnaire for each client.
Must assess each client for whether he/she had physical examination
within last 12 months; if none, then physician, registered nurse
practitioner, or physician’s assistant must conduct an exam within 30
calendar days of the client’s admission to treatment date OR must
include a goal within the client’s initial and updated treatment plans to
obtain a physical examination until completed.
Must evaluate each client to diagnose DSM 5 substance use disorder
within 30 calendar days of the client’s admission to treatment date; must
be completed by a physician OR can be done by therapist, physician
assistant, or nurse practitioner (with review/approval of a physician).
Must determine medical necessity within 30 calendar days of a client’s
admission to treatment date (must be determined by physician).
Must conduct laboratory tests (Naltrexone and NTP clients) and certify
fitness for treatment (Naltrexone clients).
Must be completed, signed and dated within 30 calendar days of a
client’s admission to treatment date and signed by the therapist or
counselor and the client (28 calendar days for NTP clients).
Must be reviewed for medical necessity by physician, signed and dated
15 calendar days of the signature of the therapist or counselor.
Must be completed, signed and dated by a therapist or counselor no later
than 90 calendar days after signing the initial treatment plan, and no later
than 90 days calendar days thereafter or when a change in problem
identification or focus of treatment occurs.
Must be reviewed, approved, signed and dated by client indicating
whether client participated in the preparation of the plan within 30
calendar days of the signature of the therapist or counselor.
Must be reviewed for medical necessity by physician, signed and dated
15 calendar days of the signature of the therapist or counselor.
Must determine need for continued treatment no sooner than 5 months
and no later than 6 months after client admission to treatment date or
date of completion of most recent justification for continuing services.
Must be determined and documented by a physician.
Substance Use Disorder Treatment Provider Manual
Key SUD Intake, Admission and Treatment Process Milestones
Must be completed for all discharged clients by the therapist or
counselor within 30 calendar days prior to the last face-to-face treatment
with the client.
Must be signed by the therapist or counselor and the client with a copy
provided to the client and placed in the client record.
Must be completed by the provider within 30 calendar days of the last
face-to-face contact for each client with whom the provider has lost
contact and for all involuntary discharges.
11
Intake, Assessment and Admission Requirements3
The first step in the treatment process is client intake and assessment. Drug Medi-Cal
requires all providers to have written documentation on procedures for client admission to
SUD treatment. The SFHN-BHS is adopting this standard for all SUD treatment providers
regardless of their DMC certification status.
Substance Use Disorder Treatment Provider Manual
A client admission to treatment date is the date on which any face-to-face treatment service is
provided to a client. Once an individual has completed the intake and assessment process,
the individual becomes a client of the program.
12
All SUD treatment providers, regardless of DMC certification status, must complete a personal,
medical and substance use history4 for each client upon admission to treatment to support the
treatment plan for each client. In addition, all providers must complete a SFHN Health
Questionnaire for each client and enter the required information into Avatar, the SFHN-BHS
electronic behavioral health record system.
For DMC certified programs, a licensed physician must review each client’s history within 30
calendar days of each client’s admission to treatment date.
Physical Examinations5
Substance use can complicate and lead to serious health conditions making it important to assess
medical illnesses that clients may face. If left untreated, significant medical illnesses may lead to
poor treatment outcomes and years of life lost. Additionally, a central element of the San
Francisco Health Network’s philosophy of care is to provide “whole person care” that meets a
client’s behavioral health and primary care needs wherever a client accesses services. All SUD
treatment providers, regardless of DMC certification status, must consider client physical health
information when developing SUD treatment plan goals.
For DMC certified programs, all clients must be assessed for whether they have had a physical
examination within the twelve-month period prior to admission to treatment. Physical
examination waivers are no longer allowable for DMC certified providers. Consistent with the
SFHN-BHS philosophy of care, the SFHN-BHS is adopting this DMC physical examination
standard for all SUD treatment providers regardless of their DMC certification status. If
documentation of a physical examination cannot be obtained, providers must describe in the
client record efforts taken to obtain documentation.
For all clients in DMC certified programs that had physical exams within the twelve months
prior to treatment admission, a physician must review the exam within 30 calendar days of the
treatment admission date to determine whether the client has any significant medical illnesses. A
copy of the physical exam must be included in the client record. For any significant medical
illnesses, the client’s initial and updated treatment plans must incorporate a goal to obtain
appropriate treatment for the illnesses. For non-DMC certified providers, program staff must
consider client physical health information in developing and updating client treatment plans.
When there is no documentation of a client physical exam within the last twelve months from
the admission to treatment date, DMC certified providers must either incorporate a physical
3
Section 51341.1(h), Title 22, CCR
4
Section 51341.1(b)(13), Title 22, CCR
5
Section 51341.1(h)(1)(A)(iv)(a)(b)&(c), Title 22, CCR
exam as a client goal in the initial and updated treatment plans or conduct a physical exam of
the client within 30 calendar days of the admission to treatment date. A physician,
registered nurse practitioner or physician’s assistant may conduct the exam. A copy of the
exam must be included in each client record. It is not sufficient to include a progress note
alone that the exam was completed. The SFHN-BHS is adopting this DMC standard for all
SUD treatment providers regardless of their DMC certification status.




Has a documented history of opiate addiction;
Is at least 18 years of age;
Has been opiate free for a period of time to be determined by a licensed physician
based on the physician’s clinical judgment (this includes the administration of a body
specimen test to confirm the opiate free status of the client); and
Is not pregnant (a client must be discharged from treatment if she becomes pregnant
during treatment).
In addition, a licensed physician must certify each client’s fitness for treatment based on the
client’s physical examination, medical history, and laboratory results. The physician also
must advise each client of the overdose risk should he or she return to opiate use while taking
Naltrexone and the ineffectiveness of pain relievers while on Naltrexone.
Narcotic Treatment Program Admission Requirements6
For DMC certified programs providing Narcotic Treatment Program services, the following
DMC regulations must be met before an individual may be admitted into detoxification or
maintenance treatment.
The medical director (licensed physician) must conduct a medical evaluation or document the
review and concurrence of a medical evaluation for each client which includes at a minimum:
1. A medical history, including the individual’s history of illicit drug use;
2. Laboratory tests for determination of narcotic drug use, tuberculosis and syphilis
(unless the medical director has determined the individual’s subcutaneous veins are
severely damaged to the extent that a blood specimen cannot be obtained); and
Substance Use Disorder Treatment Provider Manual
Naltrexone Treatment Admission Requirements
All Naltrexone treatment providers must comply with the following requirements in addition
to client intake and admission requirements listed in the prior section above. Naltrexone
providers must confirm that each client meets all of the following requirements:
3. A physical examination including, at minimum, the following:
a. An evaluation of the individual’s organ systems for possibility of infectious
diseases; pulmonary, liver or cardiac abnormalities; and negative dermatologic
impacts of addiction;
b. A record of the individual’s vital signs (temperature, pulse, blood pressure and
respiratory rate);
c. An examination of the individual’s head, ears, eyes, nose, throat (including
thyroid), chest (including heart, lungs, and breasts), abdomen, extremities, skin
and general appearance;
6
Section 10270, Title 9, CCR
13
d. An assessment of the individual’s neurological system; and
e. A record of the physician’s overall impression which identifies any medical
condition or health problem for which treatment is warranted.
In addition, before a client can be admitted to detoxification or to maintenance treatment, the
medical director (licensed physician) must:
Substance Use Disorder Treatment Provider Manual
1. Document the evidence or review and concur with the documentation of evidence used
from the medical evaluation to determine physical dependence and addiction to opiates;
and
2. Document the final determination concerning physical dependence and addiction to
opiates.
Perinatal Treatment Admission Requirements7
SUD treatment providers serving pregnant and postpartum women must meet additional
admission criteria that include:




Confirming that a client is eligible for and received Medi-Cal during the last month of
pregnancy;
Having medical documentation that substantiates the client’s pregnancy and last day of
pregnancy;
Receiving enhanced reimbursement rate only during pregnancy and for the 60-day
postpartum period beginning on the last day of pregnancy;
Terminating eligibility for perinatal treatment services on the last day of the month in
which the 60th day occurs.
Non-DMC Residential Treatment Admission Requirements8
For non-DMC residential treatment providers, initial client treatment plan requirements
include:


For short-term residential programs (a program duration of 30 days or less), the initial
treatment plan must be developed within 10 days from the client’s admission to
treatment date;
For long-term residential programs (a program duration of 31 days or more), the
initial treatment plan must be developed within 14 days of the client’s admission to
treatment date.
Initial Treatment Plan
The SFHN-BHS is adopting DMC initial treatment plan requirements for all SUD treatment
providers regardless of their DMC certification status. An initial treatment plan must be
completed, signed and dated for each client within 30 calendar days of a client’s treatment
admission date by a therapist or counselor and the client. If a client refuses to sign the treatment
plan, providers must document in the client record the reason for refusal and the strategy to
engage the client to participate in treatment.
14
For Narcotic Treatment Program clients, the initial treatment plan must be completed within 28
days after the initiation of maintenance treatment.9
7
Sections 50260, 51303, 51341.1(c)(1), 51341.1(g)(1)(A)(iii), Title 22, CCR
Section 12070, Alcohol and/or Other Drug Certification Standards
9
Section 10305, Title 9, CCR
8
Each treatment plan must be documented, individualized, and based on information obtained
during the intake and assessment. There also must be clear and documented links between
client needs, treatment goals and provided services. In addition, the rationale and
justification for the content of each of client treatment plan components must be well
documented.
In assessing treatment needs, all SUD treatment providers must consider, at a minimum,
client needs in the following areas: 1) educational opportunity/attainment; 2) vocational
counseling and training; 3) job referral and placement; 4) legal services; 5) medical and
dental services; 6) social/recreational services; and 7) individual and group counseling.









A statement of challenges to be addressed;
Goals to be reached which address each challenge identified;
Action steps which will be taken by the provider and/or client to accomplish
identified goals;
Target dates for the accomplishment of action steps and goals;
A description of the services including type and frequency of counseling to be
provided;
Client diagnosis;
A physical examination goal if the client has not had a physical exam within the
twelve months prior to the client’s admission to treatment date;
A goal that the client obtain appropriate treatment for any significant medical illness
indicated/documented by a physical examination which occurred within the twelve
months prior to treatment admission;
Include the names of the assigned primary therapist or counselor and physician.
For DMC certified providers, all initial treatment plans must be reviewed for medical
necessity by a licensed physician and signed and dated by the physician within 15 calendar
days of the date of the signature of the therapist or counselor.
For NTP providers, all initial maintenance treatment plans must include:





Short-term goals tied to client needs based on intake and admission data (specific
time 90 days or less for the client to achieve);
Long-term goals tied to client needs based on intake and admission data (specified
time in excess of 90 days for the client to achieve);
Specific behavioral tasks the client must accomplish to complete each short-term and
long-term goal;
A description of the type and frequency of counseling services to be provided;
An effective date based on the day the primary counselor signed the initial treatment
plan.
Updated Treatment Plans10
All client treatment plans must be updated, signed and dated by a therapist or counselor no later
than 90 calendar days after signing the initial treatment plan, and no later than 90 calendar days
thereafter, or when a change in problem identification or focus of treatment occurs.
10
Section 51341.1(h)(2), Title 22, CCR
Substance Use Disorder Treatment Provider Manual
Each client treatment plan must be legible and include:
15
Substance Use Disorder Treatment Provider Manual
Each updated treatment plan must include all of the components included in the initial treatment
plan and be reviewed, approved, signed and dated by client within 30 calendar days of the
signature of the therapist or counselor. The treatment plan also must indicate whether the client
participated in the preparation of the plan. If a client refuses to sign the treatment plan, providers
must document in the client record the reason for refusal and the strategy to engage the client to
participate in treatment.
16
Narcotic Treatment Program Updated Treatment Plan Requirements11
For NTP providers, updated treatment plans must be reviewed and signed within 14 calendar
days from the effective date and reviewed and signed by the medical director within 14 calendar
days form the effective date. Client updated treatment plans also must include: 1) a summary of
the client’s progress or lack of progress toward each goal identified on the previous treatment
plan; and 2) new goals and behavioral tasks for any newly identified needs or related changes in
the type and frequency of counseling services to be provided to the client; and 3) an effective
date based on the day the primary counselor signed the updated treatment plan.
Non-DMC Residential Updated Treatment Plan Requirements12
Residential treatment programs must meet the following updated treatment plan requirements:


For short-term residential programs (a program duration of 30 days or less), the initial
treatment plan must be updated within 10 days after signing the initial treatment plan and
not later than every 10 days thereafter;
For long-term residential programs (a program duration of 31 days or more), the initial
treatment plan must be updated within 14 days of after signing the initial treatment plan
and not later than every 14 days thereafter.
Client Contacts
All SUD treatment providers must meet a set of treatment plan implementation requirements
governing client contact, including the type, number and length of counseling sessions, and client
participation in treatment. These requirements may vary depending upon the SUD modality of
service and DMC requirements. The table on the next page provides a summary of client contact
requirements by modality along with documentation and group size requirements. Note that the
frequency of counseling sessions may occur more often depending on the client’s need and
recovery or treatment plan.
For SUD providers other than NTP providers, client contact requirements can be waived if a
physician determines either that fewer contacts are clinically appropriate or the client is making
progress toward treatment plan goals. Any exceptions must be noted in the individual client
record by a physician, and the physician must type or print legibly his or her name, sign and date
the record. For Narcotic Treatment Programs, the medical director (physician) may adjust or
waive this minimum number of minutes of counseling services per calendar month by medical
order. The medical director also must document his or her rationale for the medical order within
the individual client record.
Group Counseling Confidentiality
Group counseling sessions must be face-to-face and conducted in a confidential setting where
individuals not participating in the counseling session cannot hear the comments of the client or
therapist/counselor.
11
12
Section 10270, Title 9, CCR
Section 12070, Alcohol and/or Other Drug Certification Standards
Group Counseling Age Requirements
SFHN is adopting the DMC standard for age considerations for all SUD treatment providers,
regardless of DMC certification status. A client who is seventeen years of age or younger
cannot participate in group counseling with clients who are eighteen years of age or older
unless the counseling occurs at a DMC certified program’s school site.
1. The name and signature of the therapist and/or counselor conducting the counseling
session;
2. The date of the counseling session;
3. The topic of the counseling sessions.
4. The start and end time of the counseling session; and
5. Each participant’s name and signature of each participant that attended the counseling
session. The sign-in sheet must be signed at the start of or during the counseling
session.
By signing the sign-in sheet, therapists and counselors are certifying that the sign-in sheet is
accurate and complete.
Substance Use Disorder Treatment Provider Manual
Group Counseling Sign-In Requirements
All SUD treatment providers, regardless of DMC certification status, must document the
focus of group counseling sessions and must have a sign-in sheet, which includes all of the
following:
17
Table of Client Contact Requirements
SUD Modality
Substance Use Disorder Treatment Provider Manual
ODF
NTP
Minimum
Contact
Requirements
Minimum
# of
Clients
for
Groups
Maximum
# of
Clients for
Groups
# of DMC
Beneficiaries
Required per
Group
Sessions must focus
on short-term
personal, family,
employment,
educational and other
client needs and their
relationship to
substance use or a
return to substance
use.
Sessions must focus
on short-term
personal, family,
employment,
educational and other
client needs and their
relationship to
substance use or a
return to substance
use.
Each client must
receive at least
two group
counseling
sessions per
month.
No less
than 2
clients
No more
than 12
clients
Only one client
needs to be a
Medi-Cal
beneficiary
Each client must
receive a
minimum of 50
minutes of
counseling per
calendar month.
No less
than 2
clients
No more
than 12
clients
Only one client
needs to be a
Medi-Cal
beneficiary
Each client must
receive
counseling
sessions and/or
structured
therapeutic
activities a
minimum of
three hours per
day for three
days per week.
Each client must
receive
counseling
sessions and/or
structured
activities a
minimum of 20
hours per week.
No less
than 2
clients
No more
than 12
clients
Only one client
needs to be a
Medi-Cal
beneficiary
Day Care
Habilitative
Residential
18
Notes about the
Group & Progress
Note
Structured activities
must meet treatment
goals and objectives
for increased social
responsibility, selfmotivation and
integration into the
community. These
activities may include
employment,
educational or
volunteer hours
outside the program
site.
Narcotic Treatment Program - Medical Psychotherapy Sessions
For clients in NTP programs, medical psychotherapy sessions are defined as face-to-face
discussions between the medical director and/or physician and the client on issues identified
in the client treatment plan.
Individual Counseling
Individual counseling sessions between a therapist or counselor and a client must be face-toface and be conducted in a confidential setting where individuals not participating in the
counseling session cannot hear the comments of the client, therapist or counselor. Individual
counseling sessions cannot be provided via telephone, home visits or hospital visits and are
limited for ODF clients to intake, crisis intervention, collateral services and discharge
planning.
Crisis Intervention Counseling
Crisis intervention counseling must be provided face-to-face between a therapist or a
counselor and a client in crisis. A crisis must be an actual relapse or an unforeseen event or
circumstance causing imminent threat of relapse. Crisis intervention services must include a
focus on alleviating crisis challenges and must be limited to stabilization of the client’s
emergency situation.
Progress Notes
The SFHN-BHS is adopting the DMC standards for progress notes for all SUD treatment
providers regardless of DMC certification status. Progress notes tell a client’s treatment
story. While progress note requirements vary depending on the treatment modality, a client’s
therapist or counselor must document, sign and date each progress note. For ODF and
Naltrexone treatment, each progress note must include the following elements:
Substance Use Disorder Treatment Provider Manual
Collateral Services
For all SUD treatment providers, regardless of DMC certification status, collateral services
must be provided by therapists and counselors. Collateral services are defined as face-to-face
contact with significant persons in the life of the client. Significant persons are defined as
individuals that have a personal, not official or professional, relationship with the client. For
example, a client’s social worker would not meet the “significant persons” criteria. Each
collateral service must focus on the treatment needs of the client to support the achievement
of treatment plan goals. A client does not need to be present at the collateral service for the
service to billable to DMC.
1. The topic of the session;
2. A description of the client’s progress on treatment plan challenges, goals, action
steps, objectives and/or referrals;
3. Information on the client’s attendance including the date, start and end times of each
individual and group counseling session.
For Narcotic Treatment Programs, the counselor conducting the counseling session must
document for each client participating in the counseling session the:
1. Date of counseling session;
2. Type of counseling format (e.g. individual or group);
19
3. Duration of counseling session in ten-minute intervals excluding the time required to
document the session;
4. Summary of the session including one or more of the following: a) client progress toward
one or more treatment plan goals; b) response to a drug-screening specimen which is
positive for illicit drugs or negative for the replacement narcotic therapy medication
dispensed under the program; c) new issue or challenge that affects the client’s treatment;
d) nature of prenatal support provided by the program or other appropriate health care
providers; and e) goal and/or purpose of the group session, the subjects discussed, and a
brief summary of the client’s participation.
Please see the table below for progress note timeline and content requirements.
Substance Use Disorder Treatment Provider Manual
Table of Progress Note Timelines
Program Type
ODF/Naltrexone
NTP
When to Record Progress Note
For each individual and group counseling session, the therapist or
counselor who conducted the session must record a progress note
for each participating client and type or legibly print his or her
name, and sign and date the progress note within seven calendar
days of the counseling session.
The counselor must record a progress note for each participating
client within fourteen calendar days of the counseling session.
Day Care
Habilitative
The therapist or counselor must record a minimum of one progress
note per calendar week for each client participating in structured
activities including counseling sessions.
Residential
The therapist or counselor must record a minimum of one progress
note per calendar week for each client participating in structured
activities including counseling sessions.
Continuing Services13
The SFHN-BHS is adopting DMC standards for continuing service for all SUD treatment
providers, regardless of DMC certification status.
No sooner than five months and no later than six months after treatment admission or the date
of completion of the most recent justification for continuing services, the need for continued
treatment must be determined. A client’s therapist or counselor must review the client’s progress
and eligibility to continue to receive SUD treatment and recommend whether the client should
continue to receive treatment services. All of the following continuing service justification areas
must be considered in making a recommendation for continuing services:



20
13
A client’s personal, medical and substance use history;
Documentation of a client’s most recent physical examination;
A client’s progress notes and treatment plan goals; and
Section 51341.1(h)(5)(A)(i), Title 22, CCR

A client’s prognosis.
For DMC certified sites, a physician must determine whether continued services are
medically necessary. The determination of medical necessity must be documented the
physician in the client record and shall include all of the above continuing service
justification areas in addition to the therapist’s or counselor’s recommendation for continuing
services. A physician signed updated treatment plan at the six month point of treatment
services does not meet the continuing service requirement. There must be an actual
determination by a physician of the need for continued treatment based on medical necessity.
For all SUD treatment providers, regardless of DMC certification status, all billings
submitted after the date that the justification is due may be disallowed if the justification to
continue services is missing from a client record.
Narcotic Treatment Program Continuing Service Requirements
For NTP programs, the medical director and/or physician must discontinue a client’s
maintenance treatment within two consecutive years after treatment began unless the medical
director and/or physician complete the following:


Evaluates client progress or lack of progress in achieving treatment goals in the
progress notes; and
Determines through clinical judgment that the client status indicates that such
treatment should be continued for a longer period of time as discontinuance from
treatment would lead to a return to opiate addiction.
Client status in treatment must be re-evaluated at least annually after two consecutive years
of maintenance treatment. The medical director and/or physician must document the facts
justifying the decision to continue client treatment in the client record.
Discharge Plan
The SFHN-BHS is adopting the DMC standards for discharge for all SUD treatment
providers, regardless of DMC certification status.
Substance Use Disorder Treatment Provider Manual
The therapist or counselor must discharge the client from treatment if the physician
determines that continuing treatment for the client is not medically necessary.
Clients may be discharged voluntarily or involuntarily from SUD treatment. When SUD
treatment is completed and the therapist or counselor determines that the client has made
sufficient progress toward or accomplished treatment plan goals, the counselor/therapist may
discharge the client. As part of discharge, the therapist or counselor works with the client to
develop a discharge plan that must include at a minimum:


A description of the client’s relapse triggers14 and a plan to assist the client to avoid
relapse when confronted with each relapse trigger; and
A support plan.15
14
A relapse trigger is defined as event(s), circumstance(s), place(s), or person(s) that puts a client at risk of relapse (single instance
substance use or pattern of substance use).
15
A support plan is a list of individuals and/or organizations that can provide support and assistance to a client to maintain sobriety.
21
For DMC certified providers, when a physician determines that continuing treatment services is
not medically necessary, a client discharge plan must be completed by the assigned therapist or
counselor within 30 calendar days prior to the date of the last face-to-face treatment with the
client. During the last face-to-face treatment, the therapist/counselor and the client must
document their names legibly, sign and date the discharge plan. A copy of the discharge plan
must be provided to the client and must become part of the client record.
Substance Use Disorder Treatment Provider Manual
Discharge Summary
For a client with whom a provider has lost contact or who does not attend treatment for more
than 30 days, providers must discharge the client and complete a discharge summary within 30
calendar days of the date of the provider’s last face-to-face treatment contact with the client.
The discharge summary must include: 1) the duration of the client’s treatment, as determined by
the dates of admission to and discharge from treatment; 2) the reason for discharge; 3) a narrative
summary of the treatment episode; and 4) the client’s prognosis.
Narcotic Treatment Program Discharge Requirements
NTP counselors must develop a discharge summary for each client who is voluntarily or
involuntarily discharged from the program that includes at a minimum: 1) client name; 2) date of
discharge; 3) reason for discharge, and 4) summary of the client’s progress during treatment.
Client Fair Hearing Rights16
In addition to other appeal processes that may be required, DMC providers must advise clients of
their Medi-Cal fair hearing rights upon the denial, reduction or termination of DMC services as
these relate to their eligibility or benefits. This requirement applies to all clients who discharge
involuntarily as well. This notification must be in writing at least 10 calendar days prior to the
effective date of the intended action to terminate or reduce services. The written notification
must include:
1.
2.
3.
4.
A statement of the action the provide intends to take;
The reason for the intended action;
A citation of the specific regulation(s) supporting the intended action;
An explanation of a client’s right to a fair hearing for the purpose of appealing the
intended action;
5. A statement that the provider must continue treatment services pending a fair hearing
decision only if the client appeals in writing within 10 calendar days of the mailing or
personal delivery of the notice of intended action to the Department of Social Services;
6. The address where the client must submit his or her request for a fair hearing:
Department of Social Services
State Hearing Division
P.O. Box 944243, MS 9-17-37
Sacramento, California 94244-2430
1 (800) 952-5253
TDD 1 (800) 952-8349
22
Avatar and CalOMS Treatment Data Entry Requirements
California Outcomes Measurement System (CalOMS) Treatment (Tx) is California's data
collection and reporting system for SUD treatment. By entering SUD and recovery data in
16
Section 51341.1(p), Title 22, CCR
California, CalOMS Tx provides information for improving treatment client outcomes,
supporting cost effective services and meeting legally mandated federal and state reporting
requirements. Regardless of DMC certification status, all SUD treatment providers must input
client treatment data which is sent to DHCS each month.
Summary reports created from CalOMS Tx outcome data contributes to the understanding of
treatment and the improvement of substance use disorder treatment programs in the
continuum of prevention, treatment and recovery services.
Client Record and Retention Requirements
All SUD provider regardless of DMC certification status must establish, maintain, and update
as necessary an individual client record for each client admitted to treatment and receiving
services. This includes, but is not limited to:










A client identifier
Client date of birth
Client gender
Client race/ethnicity
Client address and telephone number
Client’s next of kin or emergency contact;
Client consent to treatment;
Referral source and reason for referral;
Date of admission; and
Type of admission.
In addition, providers are required to include in each client’s individual patient record
treatment episode information that includes all activities, services, sessions, and assessments
including but not limited to:










Intake and admission data, including a physical examination if applicable;
Treatment plans;
Evidence of compliance with minimum client contact requirements;
Progress notes;
Continuing services justifications;
Laboratory test orders and results;
Referrals;
Counseling notes;
Discharge plan;
Discharge summary;
Substance Use Disorder Treatment Provider Manual
All SFHN SUD treatment providers, regardless of DMC certification status, must enter
required CalOMS Tx data in Avatar. In addition to client demographic data, data entered into
Avatar builds a comprehensive picture of client behavior including alcohol and drug use data,
employment and education data, criminal justice data, medical and physical health data, mental
health data and family and social life data. In addition, Avatar captures client discharge data.
23



Evidence of compliance with multiple billing requirements;17
Evidence of compliance with specific treatment modality requirements;18 and
Any other information relating to the treatment services provided to the client.
For pregnant and postpartum women, medical documentation also must substantiate a client’s
pregnancy and the last day of pregnancy19.
Substance Use Disorder Treatment Provider Manual
All SUD providers regardless of DMC certification status must maintain the following
documentation in the individual client record for a minimum of seven (7) years from the date of
the last face-to-face contact with the client.20 If an audit takes place during the seven year
period, the provider must maintain records until the audit is completed:








Evidence that the client met admission criteria;
Treatment plan(s);
Progress notes;
Evidence that the client received counseling with any exceptions or waivers noted, signed
and dates by the physical in the client’s treatment plan;
Justification for continuing services;
Discharge summary;
Evidence of compliance with specific treatment service requirements;
Evidence that the provider complied with multiple same day service billing requirements.
A client record checklist is included under Appendix E.
Billing
SFHN Services Code Project
The SFHN-BHS has facilitated a Substance Use Disorder Treatment Services Code Project to
develop a matrix of provider service codes that incorporates definitions of service codes, DMC
units to be billed, allowable service staff, allowable location of services, advanced billing rules
and units, and EPSDT eligible services. These new services codes will be implemented as part
of the California Drug Medi-Cal Organized Delivery System Pilot program in compliance with
instructions from DHCS. For more information about the Substance Use Disorder Treatment
Services Code Project or matrix, please contact the SFHN-BHS Billing, SFMHP Claims, and
Fiscal Office at (415) 255-3536.
DMC Multiple Same Day Services21
In general, DMC will pay for only one service on a calendar day for Outpatient Drug Free and
Intensive Outpatient Treatment services. However, there are limited circumstance under which a
provider may submit a claim and be paid for a second service on a single calendar day.
For Outpatient Drug Free treatment clients, return (multiple) visits by a client on the same
calendar day must not create a hardship on a client. A statement should be included in a
24
17
Section 51490.1(b), Title 22, CCR
Section 51431.1(d), Title 22, CCR
19
Section 51431.1(g)(1)(A)(iii), Title 22, CCR
20
The Health Insurance Portability and Accountability Act, or HIPAA, requires individual client records be retained for seven (7) years.
21
Section 51341.1(p), Title 22, CCR
18
client’s chart that multiple same day services were not a hardship on the client with stated
reasons. Where multiple visits are made to the provider by a client on the same day, the
DMC provider must meet the following requirements:


Document the time of day of each visit;
Progress notes must clearly reflect that an effort to provide all services in one visit
was made and the return visit was unavoidable;
The return visit must clearly document a crisis or collateral services;
The provider must complete the DHSC MC 7700 form and place it in the individual
client record.
Where an Outpatient Drug Free second service is a group counseling session, an intake
session, a treatment planning session or a discharge planning session, the provider must
document in the progress note that an effort was made to provide all services during a single
visit and that the return visit was unavoidable.
For Intensive Outpatient Treatment clients making multiple visits to the provider on the same
calendar day, the only second service that can be billed is a crisis counseling session. DMC
certified SUD providers must meet all of the following requirements:



The return visit must clearly document a crisis service;
Crisis services must be documented in the progress notes; and
The provider must complete the DHCS MC 6700 form and place it in the individual
client record.
DMC Client Share of Cost22
All DMC clients cannot be charged any fees for treatment services except where a share of
cost requirement exists (Section 50090). All DMC providers must accept proof of eligibility
for Drug Medi-Cal as payment in full for treatment services provided. DMC providers
cannot charge fees to a client for access to DMC substance use disorder treatment services or
for admission to a DMC treatment program.
Good Cause Codes
All DMC-funded claims are supposed to be submitted within 30 days of the end of the month
that a service was provided. There are limited reasons that are considered “good cause to
submit late claims.
Substance Use Disorder Treatment Provider Manual


Program Compliance
To comply with DMC and SUD treatment and documentation requirements and to ensure
access to high quality and cost effective treatment services, the San Francisco Department of
Public Health Office of Compliance conducts annual site visits at SUD provider sites.
The Department reserves the right to broaden or narrow the scope of any compliance audit
but generally the audit will consist of a site visit to review a sampling of client charts at a
provider’s site and billing claims. Client charts will be reviewed for compliance with
treatment program standards requirements found in Title 22 and Title 9 (Narcotic Treatment
Program) of the California Code of Regulations.
22
Section 51341.1(h)(7), Title 22, CCR
25
The compliance review will verify at a minimum:






Substance Use Disorder Treatment Provider Manual

26





Client records are maintained for a minimum of 3 years for DMC certified providers;
Each client meets admission criteria including documentation of the client’s DSM 5
substance use disorder diagnosis and medical necessity;
Each client for which reimbursement was claimed has a treatment plan documenting
services claimed for reimbursement;
Services claimed for reimbursement were provided;
For DMC certified providers, services were provided at a certified location;
SUD treatment requirements were met that are contained in Section 51341.1 (b), Section
51341.1(c), Section 51341.1(d), Section 51341.1(g), Section 51341.1(h), and Section
51341.1(i) of Title 22, CCR;
Good cause codes and procedures that were used were not erroneous, incorrect or
fraudulent;
Multiple billing codes and certification processes that were used were not erroneous,
incorrect or fraudulent;
Reimbursement was not received in excess of daily limits;
Individual counseling sessions met confidentiality requirements, and for ODF, individual
counseling limitations to intake, crisis intervention, collateral services and treatment and
discharge planning were met;
Group counseling sessions met group size requirements (2 to 12 with at least one MediCal eligible client for DMC providers), confidentiality requirements, and age restrictions
for clients 17 and under;
Day care habilitative services were not less than three hours of services on calendar days
billed or provided to a non-pregnant, non-postpartum or non-EPSDT eligible client.
Additionally for narcotic treatment programs, the following requirements under Title 9, CCR,
will be reviewed, at a minimum:





Section 10270 (admission criteria time frames);
Section 10305 (treatment plan completion and review time frames);
Section 10410 (continuing treatment plan time frames);
Section 10345 (minimum counseling session requirements); and
Section 10305 (counseling session type and frequency).
A sample compliance audit tool can be found under Appendix F.
Admission to Treatment
Date
Calendar Week
Collateral Services
Counselor
Crisis Intervention
Detoxification
Treatment
Face-to-Face
Group Counseling
Illicit Drug
Individual Counseling
Intake
The date of the first face-to-face treatment service provided by
the provider to the client.
Seven (7) day period from Sunday through Saturday.
Face-to-face sessions with therapists or counselors and significant
persons in the life of a beneficiary, focusing on the treatment
needs of the beneficiary in terms of supporting the achievement
of the beneficiary's treatment goals. Significant persons are
individuals that have a personal, not official or professional,
relationship with the beneficiary.
A Certified AOD Counselor as defined in Section 13005(a)(2) of
Title 9, CCR or a Registrant as defined in Section 13005(a)(8) of
Title 9, CCR.
A face-to-face contact between a therapist or counselor and a
beneficiary in crisis. Services shall focus on alleviating crisis
problems. “Crisis” means an actual relapse or an unforeseen
event or circumstance which presents to the beneficiary an
imminent threat of relapse. Crisis intervention services shall be
limited to stabilization of the beneficiary's emergency situation.
The treatment modality whereby replacement narcotic therapy is
used in decreasing, medically determined dosage levels for a
period not more than 21 days, to reduce or eliminate opiate
addiction, while the patient is provided treatment services.
Occurring in person at a certified facility. Telephone contacts,
home visits, and hospital visits are not considered face-to-face.
Face-to-face contacts in which one of more therapists or
counselors treat two or more clients at the same time, focusing on
the needs of the individuals served.
Any substance defined as a drug in Section 11014, Chapter 1,
Division 10 of the Health and Safety Code, except: (A) Drugs or
medications prescribed by a physician or other person authorized
to prescribe drugs, pursuant to Section 4040, Chapter 9, Division
2 of the Business and Professions Code, and used in the dosage
and frequency prescribed; or
(B) Over-the-counter drugs or medications used in the dosage
and frequency described on the box, bottle, or package insert.
Face-to-face contacts between a beneficiary and a therapist or
counselor.
The process of admitting a client into a substance use disorder
treatment program and includes the evaluation or analysis of the
cause or nature of mental, emotional, psychological, behavioral
or substance use disorders; the diagnosis of substance use
disorders using the DSM-5; and the assessment of treatment
needs to provide medically necessary treatment services by a
physician. May include a physical examination and laboratory
testing.
Substance Use Disorder Treatment Provider Manual
Glossary of Terms
27
Substance Use Disorder Treatment Provider Manual
28
Outpatient counseling and rehabilitation services provided at
least three (3) hours per day, three (3) days per week to persons
with substance use disorder diagnoses, who are pregnant or
Day Care Habilitative
postpartum, and/or to Early and Periodic Screening Diagnosis,
and Treatment (EPSDT)-eligible beneficiaries.
A drug analysis laboratory approved and licensed by the State
Department of Health Services to test or analyze samples of
Laboratory
patient body specimens for the substances named in Section
10315 for a narcotic treatment program.
Also known as Levo-Alpha-Acetyl-Methadol or levomethadyl
acetate hydrochloride - the substance that can be described
Levoalphacetylmethadol
chemically as levo-alpha-6-dimethylamino-4, 4-diphenyl-3heptyl acetate hydrochloride.
Treatment modality whereby replacement narcotic therapy is
used in sustained, stable, medically determined dosage levels for
Maintenance Treatment a period in excess of 21 days, to reduce or eliminate chronic
opiate addiction, while the patient is provided a comprehensive
range of treatment services.
The physician licensed to practice medicine in California who is
Medical Director
responsible for medical services provided by the program.
A type of counseling services defined in Section 10345 of Title
Medical Psychotherapy
9, CCR.
Any opiate agonist medications that have been approved for use
in replacement narcotic therapy, including:
Medication
(A) Methadone, and
(B) Levoalphacetylmethadol (LAAM).
The prescription or administration of medication related to
substance use disorder treatment services or the assessment of the
side effects or results of that medication conducted by staff
Medication Services
lawfully authorized to provide such services and/or laboratory
testing within the scope of their practice or licensure.
A narcotic treatment facility, established by a program sponsor as
part of a maintenance treatment program, from which licensed
private practitioners and community pharmacists are permitted to
administer and dispense medications used in replacement
Medication Unit
narcotic therapy. These medication units may also collect patient
body specimens for testing or analysis of samples for illicit drug
use.
The substance that can be described as 6-dimenthylamino-4, 4diphenyl-3-heptanone. Methadone doses are usually administered
Methadone
as methadone hydrochloride.
An outpatient treatment services directed at serving detoxified
Naltrexone Treatment
opiate addicts who have substance use disorder diagnosis by
Services
using the drug Naltrexone which prevents relapse.
Any controlled substance which produces insensibility or stupor
Narcotic Drug
and applies especially to opium or any of its natural derivatives
or synthetic substitutes.
Opiate
Opiate Addiction
Outpatient Drug Free
Treatment Services
Perinatal Certified
Substance Use Disorder
Program
Perinatal Residential
Substance Use Disorder
Services Program
Physical Dependence
Physician
Relapse
Relapse Trigger
Replacement Narcotic
Therapy
Substance Use Disorder
Diagnoses
Support Plan
An outpatient service using methadone and/or
levoalphacetylmethadol (LAAM), directed at stabilization and
rehabilitation of persons who are opiate addicted and have a
substance use disorder diagnoses.
Narcotic drug substances having an addiction-forming or
addiction-sustaining liability similar to morphine or being
capable of conversion into a drug having addiction-forming or
addiction-sustaining liability; including heroin, morphine,
methadone, or any natural or synthetic opiate as set forth in the
California Uniform Controlled Substances Act (Health and
Safety Code sections 11000, et seq.).
A condition characterized by compulsion and lack of control that
lead to illicit or inappropriate opiate-seeking behavior, including
an opiate addiction that was acquired or supported by the misuse
of a physician's legally prescribed narcotic medication.
An outpatient service directed at stabilizing and rehabilitating
persons with substance use disorder diagnoses.
A Medi-Cal certified program which provides substance use
disorder services to pregnant and postpartum women with
substance use disorder diagnoses for up to 60 days after
pregnancy ends.
A non-institutional, non-medical, residential program which
provides rehabilitation services to pregnant and postpartum
women with substance use disorder diagnoses.
A condition resulting from repeated administration of a drug that
necessitates its continued use to prevent withdrawal syndrome
that occurs when the drug is abruptly discontinued.
A person licensed by the Medical Board of California or the
Osteopathic Medical Board of California.
A single instance of a client’s substance use or a client’s return to
a pattern of substance use.
An event, circumstance, place or person that puts a beneficiary at
risk of relapse.
The medically supervised use of an opiate agonist medication
that mimics the effects of endorphin, a naturally occurring
compound, thus producing an opiate effect by interaction with
the opioid receptor.
Those set forth in the Diagnostic and Statistical Manual of Mental
Disorders Third Edition-Revised or Fourth Edition, published by
the American Psychiatric Association.
A list of individuals and/or organizations that can provide
support and assistance to a beneficiary to maintain sobriety.
Substance Use Disorder Treatment Provider Manual
Narcotic Treatment
Program
29
Therapist
Substance Use Disorder Treatment Provider Manual
Unit of Service
30
Any of the following: 1) a psychologist licensed by the California
Board of Psychology; 2) a clinical social worker or marriage and
family therapist licensed by the California Board of Behavioral
Sciences; 3) an intern registered with the California Board of
Psychology or the California Board of Behavioral Sciences; or
4) a physician.
For outpatient drug free, day care habilitative services, perinatal
residential, and Naltrexone treatment services, a face-to-face
contact on a calendar day.
For narcotic treatment program services, a calendar month of
treatment services provided pursuant to this section and Chapter
4 commencing with Section 10000 of Title 9, CCR.
Substance Use Disorder Treatment Provider Manual
This page intentionally left blank.
31
ABOUT THE CONTRIBUTORS
The Substance Use Disorder Treatment Program Provider Manual was produced
through a partnership between the San Francisco Department of Public Health, substance use
disorder treatment providers, and Golden Bear Associates, a Bay Area management
consulting firm. Thank you to the following individuals for their contributions to the manual
(in alphabetical order):
Substance Use Disorder Treatment Provider Manual
Alice Gleghorn, Ph.D., Deputy Director & County Alcohol and Drug Administrator
SF Health Network – Behavioral Health Services, S.F. Department of Public Health
Valerie Gruber, Ph.D./MPH, Clinical Professor
University of California, San Francisco/San Francisco General Hospital
Department of Psychiatry
Kellee Hom, Ph.D., IS Project Director
SF Health Network – Behavioral Health Services, S.F. Department of Public Health
Chona Peralta, LCSW, DPH Compliance Officer
S.F. Department of Public Health
Judith Martin, M.D., Deputy Medical Director, Substance Use Services
SF Health Network – Behavioral Health Services, S.F. Department of Public Health
Ravi Mehta, PsyD, DPH Compliance Manager
S.F. Department of Public Health
Gilda Mansour, MSW, Compliance Manager
S.F. Department of Public Health
James Stillwell, Consultant
Karen Strickland, Principal
Golden Bear Associates/Provider Manual Producer
Denise Williams, Vice President of Compliance
HealthRIGHT 360
32
Substance Use Disorder Treatment Provider Manual
This page intentionally left blank.
33
Substance Use Disorder Treatment Provider Manual
Appendix A – SFHN-BHS Philosophy of Care
34
Substance Use Disorder Treatment Provider Manual
This page intentionally left blank.
35
San Francisco Health Network - Behavioral Health Alignment
Philosophy of Care
Substance Use Disorder Treatment Provider Manual
June 2015
Our Purpose: As members of the San Francisco Health Network (SFHN) deepen integration
efforts, its behavioral health leaders will work together to build a comprehensive behavioral
health system of care for the patients of SFHN. This includes community, urgent, emergency,
acute, long-term, and ambulatory care. By applying “Quadruple Aim”23 through the lenses of
cultural humility, wellness and recovery, we will work to meet the behavioral health needs of
San Franciscans who access care through the SFHN.
Our Philosophy of Care: Throughout the SFHN, we envision a system of care that promotes
wellness and recovery by supporting clients with mental health and substance use disorders to
pursue optimal health, happiness, recovery, and a full and satisfying life in the community via
access to a range of effective services, supports, and resources. In support of our vision, we
value the following aspects of care:
1. A trauma-informed system of care that fosters wellness and resilience for everyone in the
system, from our clients to the staff who serve them;
2. The practice of cultural humility where we make a consistent commitment to
understanding different cultures and focusing on self-humility, maintaining an openness
to someone else's cultural identity, and acknowledging that each of us brings our own
belief/value systems, biases, and privileges to our work;
3. Whole Person Care that integrates both behavioral and physical care of a client including
assessing the needs of a client’s identified family and other significant relationships;
4. Colleagues who have experienced behavioral health challenges and bring their empathy
and empowerment to recovery in others, as well as inspire and share their experience to
create a truly recovery-oriented system;
5. Valuing all clients that seek our services;
6. Shared decision making in providing the best possible coordinated care, where clients
and their providers collaborate as part of a team to make care decisions together;
7. Integration of prevention, early intervention, education, outreach, and engagement within
the continuum of care.
Our Commitments: As behavioral health leaders, we will…
36
1. Share the S.F. Department of Public Health vision as we implement change within our
organizations;
2. Promote collaboration across the SFHN in finding solutions for our common clients;
3. Designate a single point of responsibility (case coordinator) within a client’s care team to
23
The “Quadruple Aim” is based on the IHI Triple Aim framework developed by the Institute for Healthcare Improvement (IHI) that
describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously
pursue three dimensions, which we call the “Triple Aim”: 1) improving the patient experience of care (including quality and satisfaction);
2) improving the health of populations; and 3) reducing the per capita cost of health care. The SFHN-BHS has added a fourth aim for San
Francisco, improving the workforce.
Our Alignment Opportunities: We acknowledge that integration offers the SFHN opportunities
for alignment including:













Philosophy of care (wellness and recovery, team-based care);
Communication/Electronic Health Record;
Evaluation of program and staff performance and staff competency;
Single point of responsibility for high need clients (care coordination);
Utilization of local experts;
Patient flow and transitions of care;
Shared knowledge of systems;
Standardization of practice;
Productivity standards;
Standardized definitions and meaning;
Philosophy of collaboration at line staff level across system;
Appropriate level of care – commitment to stretch services to fill gaps and meet needs;
Shared accountability for all aspects of the system of care from client engagement to
regulatory compliance;
 Any door is the right door to receive seamless, coordinated, quality and appropriate care.
Substance Use Disorder Treatment Provider Manual
support client needs and preferences when a client cannot be responsible for his or her care
due to health and/or behavioral health challenges;
4. Communicate at all levels to empower our staff to communicate and find common
ground;
5. Articulate within our organizations that we are part of a larger system;
6. Create a workforce that strives for excellence and commit the resources needed to
achieve excellence;
7. Implement a trauma informed system of care;
8. Provide services with cultural humility with a priority focus on Black/African American
health disparities;
9. Address all health disparities, as well as the needs of underserved populations;
10. Promote fiscal responsibility;
11. Convene regularly to share best practices, solve challenges, and foster open lines of
communication among each other.
37
Substance Use Disorder Treatment Provider Manual
Appendix B – DPH Drug Medi-Cal Certification Requirement Checklist
38
DRUG MEDI-CAL REQUIREMENT CHECKLIST –
Is a drug and alcohol treatment program funded through the federal Medicaid program. The primary regulations that govern DMC are
contained in Title 22, Sections 51341.1 (program requirements), 51490.1 (claim submission requirements) and 51516.1 (reimbursement rates
and requirements)
Program Integrity emergency regulations for Section 51341.1 became effective on 6/25/14
This checklist is meant to help you prepare for State certification. The services provided must be contained in an approved State Medicaid
Plan (approved by CMS)
1. Agency Name
(Must match Appendix A,
database and ITWS) 1
5. Program Name
(Must match Appendix A,
database and ITWS)
8. Program Site Service
Delivery Address &
Satellite3, if any
(Must match Appendix A,
database and ITWS)
10. DPH Staff
1
2. Agency No
3. NPI No2
(Each program site location must
have its own NPI number. One
address equals one NPI number.)
4. Program
Code(s)
6. Agency Representative(s)
7. Phone No. (If Different than
Provider No.)
9. Mailing Address (If Different
Than Delivery Address)
Attn:
11. Date of Review
Note that changing an Agency’s name may necessitate a change in the NPPES system and other changes.
2
If moving, agencies must update the NPI number to exactly match the new address. Please provide a copy of the NPI number documentation to the
Certifier. https://nppes.cms.hhs.gov/NPPES/Welcome.do
3
Satellite site means a clinic based at a specific building, place or premises that is at a separate location from a DHCS certified substance abuse clinic
or OBOT that is: Licensed as a Narcotic Treatment Program; OR Affiliated and associated with a licensed narcotic treatment program or licensed OBOT.
12. Contracted Services4(Must match Attachment A, database, ITWS and/or procurement)
☐ Substance Abuse Clinic or Clinic5
☐ Office-Based Opiate Treatment6
☐ Narcotic Treatment Program7
☐ Naltrexone Treatment8
4
CCR, Title 9, Section 1840.366. Lockouts for Crisis Intervention include: (a) Crisis Intervention is not reimbursable on days when Crisis Residential
Treatment Services, Psychiatric Health Facility Services, Psychiatric Nursing Facility Services, or Psychiatric Inpatient Hospital Services are reimbursed,
except for the day of admission to those services. (b) The maximum amount claimable for Crisis Intervention in a 24-hour period is 8 hours.
5
Substance Abuse Clinic or Clinic is a Nonresidential Substance Abuse Treatment program that provides services to individuals who remain less than
24 -hours or a perinatal residential substance abuse services program. Services include evaluation, assessment, education, individual and group
counseling, replacement narcotic therapy using the medications methadone and/or levoalphacetymethadol (LAAM), naltrexone treatment, treatment
planning, treatment outcome goals, and objectives. A Substance Abuse Clinic shall provide substance abuse services more than 20 hours a week.
DHCS shall conduct an on-site inspection prior to DHCS certification.
6
Office-Based Opiate Treatment is an office-based opiate treatment program that is: Licensed as a Narcotic Treatment Program, pursuant to Section
11877.2(a) (1), Chapter 1, Part 3, Division 10.5, Health and Safety Code; or Affiliated and associated with a licensed Narcotic Treatment Program or
licensed OBOT, pursuant to Section 11877.2(a)(2), Chapter 1, Part 3, Division 10.5, Health and Safety Code. An OBOT shall submit proof of
authorization by the Narcotic Treatment Program Licensing Branch to provide services and a copy of the physician and/or pharmacy license
with the application for DMC certification.
7
Narcotic Treatment Program is an outpatient service using methadone and/or levoalphacetylmethadol (LAAM), directed at stabilization and
rehabilitation of persons who are opiate addicted and have a substance use disorder diagnoses. For the purposes of this section, Narcotic Treatment
Program does not include detoxification treatment.
8
Naltrexone Treatment includes intake, admission physical examinations, treatment planning, provision of medication services, medical direction,
physician and nursing services related to substance use, body specimen screens, individual and group counseling, collateral services, and crisis
intervention services, provided by staff that are lawfully authorized to provide, prescribe and/or order these services within the scope of their practice or
licensure. Naltrexone Treatment services shall only be provided to a beneficiary who meets all of the following conditions: has a confirmed documented
history of opiate addiction; is at least 18 year or over; is opiate free; is not pregnant. Medication Services" means the prescription or administration of
medication related to substance use disorder treatment services, or the assessment of the side effects or results of that medication conducted by staff
lawfully authorized to provide such services and/or order laboratory testing within the scope of their practice or licensure.
Page 2 of 28
Last updated: 8/28/2015
☐ Outpatient Drug Free Treatment9
☐ Regular
☐ Perinatal
☐ Residential12
☐ Day Care Habilitative (DHC)10
☐ EPSDT & Perinatal
☐ Perinatal Residential Substance Abuse
Services11
License #
9
Outpatient Drug Free Treatment means an outpatient service directed at stabilizing and rehabilitating persons with substance use disorder diagnoses.
Multiple visits on the same day must adhere to the below and shall not create a hardship on beneficiary
 Document time of day of each visit
 Progress note shall clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable;
 The return visit shall clearly document a crisis or collateral service
 The provider must complete the DHCS MC 7700 form and place in Beneficiary record
10
Day Care Habilitative (also known as Intensive Outpatient) is outpatient counseling and rehabilitation services provided at least three hours per day,
three days per week to persons with substance use disorder diagnoses, who are pregnant postpartum period, and/or to Early and Periodic Screening
Diagnosis, and Treatment (EPSDT)-eligible beneficiaries, as otherwise authorized. Multiple visits on the same day must adhere to the below and shall
not create a hardship on beneficiary
 The return visit shall clearly document a crisis service
 Crisis services shall be documented in the progress notes
 Provider must complete the DHCS MC 7700 form and place in Beneficiary record
11
Perinatal Residential Substance Abuse Services is a 24-hour freestanding residential program, which is licensed for a treatment capacity of sixteen
beds or less. Beds occupied by children who stay in the facility with their mothers are not counted in the 16-bed limit. Reimbursable services are limited
to pregnant and postpartum women with substance abuse impairments. Services include intake, assessments, diagnosis, evaluation and individual and
group counseling ad well as the perinatal program elements listed in Title 22, CCR, Section 51341.1. "Perinatal residential substance use disorder
services program" means a non-institutional, non-medical, residential program which provides rehabilitation services to pregnant and postpartum women
with substance use disorder diagnoses. Each beneficiary shall live on the premises and shall be supported in her efforts to restore, maintain, and apply
interpersonal and independent living skills and access community support systems. Programs shall provide a range of activities and services for
pregnant and postpartum women. Supervision and treatment services shall be available day and night, seven days a week.
12
In order to participate in the DMC Program for substance abuse treatment services provided within a residential setting, a licensed residential
alcoholism or drug abuse recovery or treatment facility shall be DMC certified to provide perinatal residential substance abuse services. DMC certified
perinatal residential substance abuse service programs shall be limited to billing DMC for treatment services as described in Title 22, CCR, Section
51341.1.
Page 3 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
I. General Management
A. Governing Body – Each program shall have a governing body, which has legal authority for
☐
☐
☐
operating the program. Each program must have:
 Meeting minutes available to the public
 Bylaws and rules of program shall follow applicable legal requirements
 Documentation of legal authority for the formation of the agency15
B. Chief Executive Officer – The governing body shall appoint a chief officer and list major duties,
☐
☐
☐
authority and qualifications.
C. Personnel Policies
☐
☐
☐
1. Shall be:
☐
☐
☐
 Written and revised as needed and approved by the governing body
 Applicable to all employees and reviewed with new employees;
 Comply with applicable local, state and federal employment practice laws;
 Contain information about the following:
o Recruitment, hiring, evaluation, promotion, disciplinary action & termination
o Equal employment opportunity, non-discrimination and affirmative action policies
o Employee benefits, training development & grievance procedures
o Salary schedule, merit adjustment, severance pay, rules of conduct;
o Employee safety and injuries
o Physical health status, as required
2. Personnel files shall be maintained on all employees and shall contain:
☐
☐
☐
 Application for employment and resume
13
The standards included in this document identify minimal requirements for Drug Treatment Programs within the State of California. They apply to all
programs designated as treatment services in each County Plan and funded wholly or in part through the DHCS. Only those policies and procedures
considered absolutely essential are specifically identified in these minimal standards. Requirements identified elsewhere - such as Confidentiality
Regulations (42 CFR Part 2), Methadone Regulations (Title 9), "Proposed Short-Doyle Medi-Cal Certification Standards", and Short-Doyle Community
Services Systems Manual are not repeated in this document. In case of conflicts the most restrictive requirement shall apply.
14
Request for exceptions to the standards shall be submitted to the appropriate funding source(s) with a full explanation and justification. These
exceptions shall be granted only if the quality of treatment is not significantly reduced or when application of these standards makes the program cost
ineffective.
15
Public organizations shall provide an organization chart which reflects the program's placement within a government agency.
Page 4 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
 Employment confirmation statement
 Salary schedule and adjustment
 Employee’s evaluation
 Health records, as required
 Other personnel actions
3. Procedures shall be established for access to and confidentiality of personnel records.
☐
☐
☐
4. Job descriptions shall be developed, revised as needed and approved by the governing body.
☐
☐
☐
These shall include:
 Position title and classification
 Duties and responsibilities
 Lines of supervision
 Education, training, work experience and other qualifications for the position
5. A written code of conduct for employees and volunteers shall be established which address
☐
☐
☐
at least the following:
 Use of drug and/or alcohol
 Relationship between staff and clients
 Prohibition of sexual contact with clients
 Conflict of interest
D. Fiscal Management
☐
☐
☐
1. Each program shall have an annual written budget, which includes income and expenses
☐
☐
☐
and:
 Lists all income by source
 Lists all expenses by program component or service type
2. Each program shall use the Uniform Method of Determining Ability to Pay (UMDAP) as the
☐
☐
☐
fee schedule for collecting fees.
3. Each program shall develop a reporting mechanism, which indicates the relation of the
☐
☐
☐
budget to actual income expenses to date.
4. Each program shall maintain written policies and procedures that govern fiscal management
☐
☐
☐
systems (e.g. purchasing authority, accounts receivable, cash, billings and cost allocation)
5. Program personnel responsible for signing checks and performing other accounting activities
☐
☐
☐
shall be bonded.
6. The fiscal management system shall provide for an audit of the financial operations of the
☐
☐
☐
program at least every two years by either a public accountant who is not a staff or Board
member or by the funding agency.
Page 5 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
E. Volunteer Services – if a program utilizes the services of volunteers, it shall develop and
☐
☐
☐
implement policies and procedures that address:
 Recruitment
 Screening
 Selection
 Training and orientation
 Duties and assignments
 Supervision
 Evaluation
 Protection of client confidentiality
II. Program Management
A. Admission or Readmission 1. Criteria – Each program shall include a written admission and readmission criteria for Beneficiary and program ☐
☐
☐
determining client eligibility16 and suitability for treatment. These shall include:
staff must not sign blank or
incomplete documents.
 Identification of drug abuse
 Documentation of social, psychological, physical and/or behavioral problems related to
drug abuse
 Statement of nondiscrimination
2. Intake17 – Each program shall have a written intake procedure with accompanying The Intake/Assessment is
☐
☐
☐
documents, which shall include:
the basis for establishing
Medical Necessity. The
 An initial interview to determine whether or not a client meets the admission criteria
16
Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full
for treatment services rendered. Providers shall not charge fees to beneficiary for access to Drug Medi-Cal substance use disorder services or for
admission to a Drug Medi-Cal treatment slot.
17
Intake means the process of admitting a beneficiary into a substance use disorder treatment program. Intake includes the evaluation or analysis of the
cause or nature of mental, emotional, psychological, behavioral, and substance use disorders; the diagnosis of substance use disorders utilizing the
Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition, published by the American Psychiatric Association; and
the assessment of treatment needs to provide medically necessary treatment services by a physician licensed to practice medicine in the State of
California. Intake may include a physical examination and laboratory testing (e.g., body specimen screening) necessary for substance use disorder
treatment and evaluation conducted by staff lawfully authorized to provide such services and/or order laboratory testing within the scope of their practice
or licensure.
Page 6 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
 If a client does not meet the admission criteria, the client shall be referred elsewhere for evaluation or analysis of
the cause or nature of the
treatment
 All clients admission shall meet the admission criteria and this shall be documented in disorders listed below
using DSM codes: Mental,
the client file
 If a client is appropriate for treatment, the following information shall be gathered, at Emotional, Psychological,
Behavioral, Substance Use
minimum:
o Social economic and family background
Intake/Assessment
may
o Education
also include a physical
o Vocational achievements
examination and laboratory
o Criminal history, legal status
testing by staff lawfully
o Medical history
authorized to provide such
o Drug history
services
o Previous treatment
 Only upon completion of this process and signing of the consent form shall the client be
For each beneficiary, the
admitted to treatment.
provider shall complete:
 Personal history
 Medical history
 Substance use history
 Assessment of the
physical condition
3. Medical Assessment – A complete medical and drug history shall be taken. The program A physical examination can ☐
☐
☐
shall take reasonable steps to protect clients form the spread of infectious diseases. An be conducted by the
assessment of physical conditions shall be made within 30 days of admission and program’s physician,
documented in the client file in one of the following ways:
registered nurse
practitioner or physician’s
assistant, within thirty (30)
days of admission
OR
Physician can review
documentation of most
recent (within 12 months)
physical examination
OR
Page 7 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
 A physical examination18 by a physician19, registered nurse practitioner or physician’s Include obtaining a
physical examination as a
assistant
 Upon review of the medical history and other appropriate material a determination shall treatment plan goal.
be made by a licensed physical of the need for physical and laboratory examinations. Any
Physical Examination
recommended examination shall be made available either directly or by referral.
Waivers are no longer an
option for Drug Medi-Cal
Programs
B. Services
1. Staffing – Each program shall be staffed to ensure adequate delivery of required and provided
☐
☐
☐
services as approved.
2. Hours of Operation – Each program shall provide sufficient scheduled hours or service to
☐
☐
☐
meet the needs of clients. The hours shall be set so that clients may utilize services without
undue inconvenience. When not open, the program shall provide information concerning
availability of short-term emergency or referrals.
18
If a beneficiary had a physical examination within the twelve month period prior to the beneficiary's admission to treatment date the physician shall
review documentation of the beneficiary's most recent physical examination within thirty calendar days of the beneficiary's admission to treatment date.
If a provider is unable to obtain documentation of a beneficiary's most recent physical examination, the provider shall describe the efforts made to obtain
this documentation in the beneficiary's individual patient record. As an alternative to or in addition to complying with above, the physician, a registered
nurse practitioner or a physician's assistant may perform a physical examination of the beneficiary within thirty calendar days of the beneficiary's
admission to treatment date. If the physician has not reviewed the documentation of the beneficiary's physical examination as described above or the
provider does not perform a physical examination of the beneficiary as provided for above, then the provider shall include in the beneficiary's initial and
updated treatment plans the goal of obtaining a physical examination, until this goal has been met.
19
Physician means a person licensed as a physician by the Medical Board of California or the Osteopathic Medical Board of California
Page 8 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
3. Counseling and Other Therapeutic Services
Group Counseling must be ☐
☐
☐
a. Frequency of Services – Program shall have written protocols and implement the conducted in a confidential
following, respective to the service offered20:
setting and have a group
 Outpatient – Each client shall be seen weekly or more often, as indicated by the sign-in sheet that includes:
treatment plan. At minimum all clients shall receive two counseling sessions per 30  A typed or printed list of
day period or be subject to discharge.
the beneficiary’s names
and the signature of
 Residential – Each client shall receive a minimum of twenty hours per week of
each beneficiary that
counseling and/or structured therapeutic activities
attended the counseling
 Day Treatment – Each client shall receive a minimum of ten hours per week of
session. Provider staff
counseling and/or structured therapeutic activities
may not sign beneficiary
b. Type of Services - The need for the following minimum services must be assessed and
names
onto
any
when needed, shall be provided directly or by referral to an ancillary service. These
document
or
sign-in
services include, but are not limited to:
sheet.
 Educational opportunities
 A typed or printed name
 Vocational counseling and training
and
signature
of
 Job referral and placement
counselor(s)
facilitating
 Medical and dental services
session
(certifying
 Social/recreational services
accuracy
and
completeness)
 The
date
of
the
counseling session
 The start and end times
of
the
counseling
session
o The topic of the
counseling
session
20
Exceptions to above frequency of services may be made for individual clients where it is determined by program staff that fewer contacts are clinically
appropriate and that progress toward treatment goals is being maintained. Such exceptions shall be noted in the client file.
Page 9 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
Providers may not sign
 Individual21 and group counseling22 for clients and significant persons23
o Group counseling sign-in sheets shall be maintained, which shall include the beneficiary names to any
document or sign-in sheet.
following: , name, date, start and end time, signature
21
Individual Counseling is face-to-face contacts between a beneficiary and a therapist or counselor at a DMC certified location. Individual counseling
shall be conducted in a confidential setting, so that individuals not participating in the counseling session cannot hear the comments of the beneficiary,
therapist or counselor. Individual counseling shall be limited to intake crisis intervention, collateral services, and treatment and discharge planning. For
ODF, Individual Counseling is limited to: Intake/Assessment; Treatment Planning; Discharge Planning; Collateral; and Crisis.
22
Group Counseling is face-to-face contacts in which one or more therapists or counselors treat two or more clients at the same time, focusing on the
needs of the individuals served. Group counseling sessions shall focus on short-term personal, family, job/school, and other problems and their
relationship to substance use or a return to substance use. Services shall be provided by appointment. Each beneficiary shall receive at least two group
counseling sessions per month. Group counseling shall be conducted in a confidential setting, so that individuals not participating in the group cannot
hear the comments of the group participants, therapist or counselor.
Page 10 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
4. Referral Services - If during the course of treatment it is judged that a client is not appropriate
☐
☐
☐
for treatment, or is in need of other services, the program shall provide the client with a referral
to appropriate alternative services. Program policies and procedures shall identify the
conditions under which referrals are made, the procedures for making and following-up the
referrals, and the agencies to which referrals may be made.
5. Medical Services – Each program shall have policies and procedures for:
☐
☐
☐
 Emergency
 Consulting
 Medical Detoxification
C. File Management
1. Programs shall establish and control all client records:
☐
☐
☐
 A client file shall be established for each client admitted to the program
 All client files shall be maintained. Information shall only be released in accordance with
42 CFR Part 2.
2. Content of Records – All client files shall be signed, dated, legible, have a standard format Program staff may not back ☐
☐
☐
and easily accessible to staff providing services, and contain the following, at minimum:
or forward date any
signatures.
 Demographic and identifying data
o Client identifier (i.e. name, number, etc.)
Beneficiary and program
o Date of birth
staff must not sign blank or
o Sex
incomplete documents.
o Race/ethnicity
o Address
o Phone number
Modality
Outpatient Drug-Free
(ODF)
Minimum Maximum
2
12
Day Care Habilitative 2
(DCH)
23
12
Group Counseling
Billing
In order to bill DMC, at least one of the two to
twelve participants must be a DMC Beneficiary
In order to bill DMC, at least one of the two to
twelve participants must be a DMC beneficiary
Age Limits
A beneficiary that is under the age of 18
years cannot participate in group counseling
sessions with any participants that are 18
years or older UNLESS the group
counseling sessions are held at a
provider’s certified school site
Significant persons are individuals that have a personal, not official or professional, relationship with the beneficiary.
Page 11 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
 Next of kin, emergency contact with phone number
All Treatment Plans must
 Consent to treat
have:
 Referral source and reason for referral
1. A statement of the
 Date of admission
problems to be address;
 Type of admission (i.e. new)
2.
Goals to be reached,
 All information gathered during intake shall also be included in the client file
which address each
 Treatment Plan – Each client shall have an individual treatment plan, which is based upon
stated problem;
the information obtained during the intake and assessment process. The treatment plan
shall be developed within 30 days from the client’s admission. The treatment plan shall 3. Action steps, which will
be taken by the provider
be updated at least every 90 days and shall include the following:
and/or Beneficiary to
o Statement of problem(s) to be addressed in treatment
accomplish each goal;
o Statement of goals to be reached which address the problem(s)
4.
Targeted
dates for
o Action steps which will be taken by program and/or client to accomplish goal(s)
accomplishments
of
o Target dates for accomplishments of action steps, goals and resolution of
steps for each goal;
problem(s)
5. Description
of
the
 Urine Surveillance – When drug screening by urinalysis is deemed appropriate by the
services, including type
program director or supervising physician, the program shall:
and frequency (Group
o Established written procedures which protect against the falsification and/or
counseling must be a
contamination of any urine sample
specific
number
of
o Document urinalysis results in client files
sessions over a specific
 Other information required
period of time. If
o The documentation of all services which show the relationship of services to
Individual Counseling is
treatment plans
planned, it must be on
o The documentation of quality assurance procedures
the Treatment Plan.
o Progress notes which state clients' progress toward reaching goal(s).
6. Assignment of a primary
therapist or counselor
7. The beneficiary’s DSM
code diagnosis
8. Physical Examination.
3. Disposal and Maintenance of Files
☐
☐
☐
 Closed programs – In the case of a program closing, all client records shall be stored in
an appropriate confidential manner by the County for no less than four years
Page 12 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
 Closed cases – There shall be a written policy in all programs regarding the maintenance
and disposal of client records. All records shall be stored in an appropriate confidential
manner for no less than four years from the date they are officially closed.
D. Quality Assurance – Each program shall have written policies and procedures for quality
☐
☐
☐
assurance. These shall include the following:
 Continuity of Care – the program shall provide for a staff person for the clients’ continuity
of care that at least the following take place:
o A treatment plan is developed at the earliest practical time after admission, but
not to exceed 30 days
o Services required are provided and documented in the client file
o Failure of client to keep scheduled appointments is discussed with client and
documented
o Progress in achieving goals and objectives identified in the treatment plan are
assessed and documented on a continuous basis
o The treatment plan is periodically reviewed and updated, at least every 90 days
o The client file contains all required documents (e.g. correspondence, authorization
to release information, consent for treatment, etc.)
o If feasible, the client is followed up with after treatment as scheduled in the
discharge summary
 Case and Treatment Plan Reviews - The treatment review plan shall:
o Assess progress to date
o Reassess needs and services
o Identify additional problem areas and formulate new goals, when appropriate
 Program Evaluation – each program shall have written self-evaluation procedures for
management decision making, which shall be included in the program’s policies and
procedures.
 Follow-up – Each program shall have follow-up procedures for clients who remain the
community after discharge.
 Staff Development – each program shall have a written plan for training needs for all staff
and document such training/events.
 Utilization Review – Each program shall have written procedures for utilization review
 Facility Management – Each program’s facility shall comply with all applicable local, state
and federal laws and regulations. Procedures shall be developed to ensure the facility will
be maintained in a clean, safe and sanitary and drug-free condition.
E. Client Rights
Page 13 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
1. A document shall be prepared and provided to each client upon admission or posted in a
☐
☐
☐
prominent place, accessible to clients, which shall include the following:
 A statement of nondiscrimination by race, religion, sex, ethnicity, age, disability, sexual
preference and ability to pay
 Client rights
 Grievance procedures
 Appeal process for denial or discharge24
 Program rules and regulations
 Client fees
 Access to treatment files in accordance with Executive Order #B-22/76
2. Confidentiality – All programs shall comply with 42 CFR, Part 2 and Article 7 (commencing Beneficiary and program ☐
☐
☐
with Section 5325) of Subchapter 2, Part 1 of Division 5 of the Welfare and Institution Code. staff must not sign blank or
In addition, all methadone programs shall comply with Sections 11875-11882 of the Health incomplete documents.
and Safety Code.
3. Consent to Treatment - Each program shall develop a consent to treatment
Beneficiary and program ☐
☐
☐
(or admission agreement) form, which shall be read and signed by client upon admission. staff must not sign blank or
This form shall advise clients of his/her obligations as well as those of the program.
incomplete documents.
4. Consent for Follow-Up - The follow-up after discharge cannot occur without a written consent Beneficiary and program ☐
☐
☐
from the client.
staff must not sign blank or
incomplete documents.
5. Research - Any program conducting research using clients s subjects shall
☐
☐
☐
24
Per Section 51341.1 (p) Providers shall inform beneficiaries of their right to a fair hearing related to: Denial; Involuntary discharge; or Reduction in
DMC services. At least ten calendar days prior to the effective date of the intended action the provider must give the beneficiary a written notice that
includes:
 A statement of the action the provider intends to take
 The reason for the intended action
 A citation of the specific regulation(s) supporting the intended action
 Informing the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended action
 Informing the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the notice
 Must include the address where the request for a fair hearing must be submitted
Page 14 of 28
Last updated: 8/28/2015
TREATMENT STANDARDS13 - Each program shall develop a written protocol indicating compliance with all of the standards contained
herein which shall be approved by the appropriate funding source(s).14
Criteria & What the Agency Must Do
Yes
No
N/A
comply with all standards of the California Research Advisory Panel and the federal
regulations for protection of human subjects (45 CFR 46).
F. Discharge – Each program shall have written procedures regarding client discharge, which shall
☐
☐
☐
contain the following:
1. Written criteria, which defines:
 Successful completion of the program
 Unsuccessful discharge
 Involuntary discharge
 Transfers and referrals
2. A discharge summary, which includes:
☐
☐
☐
 Description of treatment episode
 Current drug usage
 Vocational/educational achievements
 Criminal activity
 Reason for discharge
 Client’s discharge plan25
 Referrals
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
GENERAL REQUIREMENTS
A. Fire Clearance
Completed?
Yes
No
N/A
☐
☐
☐
Notes
Each clinic shall conform with the rules and regulations
adopted by the State Fire Marshal and the requirements of
the local fire authority. Each clinic shall have a copy of the
valid fire clearance.26
26
In lieu of a fire clearance, a clinic that is located at a public school site may provide a letter from the school principal that certifies that all services
provided at the public school site meet fire safety rules and regulations.
Page 15 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
Completed?
B. Use Permits
Yes
☐
No
☐
N/A
☐
Approval shall be secured by the local agency authorized to
provide building use permit. If the local agency authorized to
provide a building use permit does not require a use permit,
the clinic shall obtain a letter from the local agency attesting
to the circumstances.27
C. Accessibility of Service
☐
☐
☐
Services shall be accessible to the disabled.
D. Physical Plant
☐
☐
☐
The clinic shall be clean, sanitary, and in good repair at all
times. Maintenance shall include provisions and surveillance
of maintenance services and procedures for the safety and
well-being of patients, personnel, and visitors.28
E. Utilization Review
☐
☐
☐
☐
☐
☐
The provider shall establish, implement, and maintain
procedures.29
F. Client Health Records
1. Each provider shall establish and maintain a patient
health record on every patient admitted for care at the
clinic
27
Notes
In lieu of a local use permit, a clinic or satellite site that operates on a public school campus shall obtain a letter authorizing the provision of services at
the public school from the school principal.
28
Health and Safety Code, Sections 208(a) and 1275
29
Title 22, CCR, Section 51341.1
Page 16 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
2. All health records of discharged patients shall be
completed and filed in a secure and confidential
location within 30 days after discharge, and such
records shall be kept for a minimum of three years30
3. Information contained in health records shall be
confidential and shall be disclosed only to authorized
persons in accordance with federal, state, and local
laws31.
G. Administrative Policies
1. Written administrative policies and procedures
regarding patient health records implemented,
maintained, reviewed annually and revised as
necessary
2. Written administrative policies and procedures
regarding personnel files implemented, maintained,
reviewed annually and revised as necessary and
include:
a) Application for employment and/or resume
b) Employment confirmation statement
c) Salary schedule and salary adjustment information
d) Evaluations
e) Health records, as required
f) Other personnel actions (e.g. commendations,
discipline, status change, employment incident
and/or injuries)
3. Procedures for access to and confidentiality of
personnel records.
30
Title 22, CCR, Section 51341.1 (i)
31
Title 9, CCR, Section 10155
Page 17 of 28
Last updated: 8/28/2015
Completed?
Yes
☐
No
☐
N/A
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
4.
Job descriptions shall be developed, revised as
needed, and approved annually by the governing
body. The job descriptions shall include:
a) Position title and classification;
b) Duties and responsibilities;
c) Lines of supervision, (if applicable);
d) Education, training, work experience and other
qualifications for the position.
5. A written code of conduct for employees and
volunteers shall be established, which addresses at
least the following:
a) Use of drugs and/or alcohol;
b) Prohibition of sexual contact with clients; and
c) Conflict of interest
H. Health Records
1. All persons working in the clinic, including volunteers,
shall have a health screening within six months prior
to employment or within 15 days after employment.
2. The provider shall maintain a health record for each
employee, which includes reports of all employment
related health examinations. These should be kept for
a minimum of three years following termination of
employment.
3. All persons working in the clinic shall have been
screened and those who are found to have symptoms
of infectious disease shall be removed from contact
with clients.
I. Basic Services
1. A DSM diagnosis32 and evaluation toward formulation
of a continuing treatment plan is provided.
32
Completed?
Yes
☐
No
☐
N/A
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes
Substance use disorder diagnoses are those set forth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth
Edition, published by the American Psychiatric Association. The physician shall document the basis for the diagnosis in the beneficiary's individual
patient record.
Page 18 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
2. A medication maintenance program is provided, if
appropriate.
3. Individual and/or group therapy or counseling is
provided.
G. Perinatal Services – An enhanced type of certification for
a clinic that provides additional services for pregnant and
postpartum women
Beneficiary must be eligible for and
received Medi-Cal during the last month
of pregnancy.
Must have medical documentation that
substantiates the Beneficiary’s
pregnancy and last day of pregnancy.
Rate is applicable during pregnancy
and for the 60-day postpartum period
beginning on the last day of pregnancy
Eligibility ends on the last day of the
month in which the 60th day occurs
1. Mother/Child Habilitative and Rehabilitative Services –
Perinatal clinics provide habilitative services that
include interactive parenting skills building and child
development training. The provider may hire staff
specifically for these duties, or they may be
incorporated into the duties of other positions (e.g.,
counselor). Parenting skills building and child
development staff shall provide the mothers with
positive role modeling, education, instruction and
structured activities. At no time shall staff provide child
care.
Page 19 of 28
Last updated: 8/28/2015
Completed?
Yes
☐
No
☐
N/A
☐
☐
☐
☐
Notes
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
Completed?
Yes
No
N/A
Notes
The interactive skills building and child development
training can be provided through the program’s on-site
cooperative child care component. On-site
cooperative child care is defined by the following
elements:
a) Child development staff provide the mothers with
parenting skills training, child development
education, and supportive role modeling;
b) The mothers are on-site and the children are
under their care and supervision; and
c) The number of children is limited to 12 or less at
any one time33.
2. Service Access - Perinatal clinics shall provide or
arrange for transportation to and from medically
necessary treatment and other Medi-Cal covered
services, such as primary medical care and pediatric
care, for pregnant and postpartum women who do not
have their own transportation.
3. Education - Pregnant and postpartum women require
medically necessary prevention and education
intervention to reduce harmful effects of alcohol and
drugs on mother and fetus or mother and infant.
Perinatal clinics shall provide education and training
on:
a) The impact of substance abuse during pregnancy;
b) The impact of substance abuse while breast
feeding;
c) Environmental impact of substance abuse on
infant;
33
For more information on cooperative child care, refer to the California Health and Safety Code, Section 15986.792. Child care also may be provided
through on-site licensed child care or offsite licensed child care for the children of clients receiving treatment, however, Perinatal DMC will not reimburse
clinics for the cost of licensed child care whether it is provided on or off-site.
Page 20 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
d) HIV/AIDS transmission and access to testing; and
e) Tuberculosis and access to testing.
4. Coordination of Ancillary Services - Pregnant an
postpartum women shall receive medically necessary
assistance to access and complete required
appointments to ancillary services, such as other
medical services, dental services, necessary social
services, community services, and
educational/vocational training.
STAFF
A. Medical Director/Medical Responsibility
1. Each clinic shall have a licensed physician designated
as the medical director. All medical services provided
by the clinic shall be under the direction of a
physician, who shall be available on a regularly
scheduled basis and otherwise on call. The medical
director shall assume medical responsibility for all
clients. The medical director shall direct medical
services, either by acting alone or through an
organized medical staff.
2. The medical director’s responsibilities, acting alone or
through an organized medical staff, shall include:
No signature stamps are allowed.
a) Establishing, reviewing, and maintaining medical
policies and standards.
b) Assuring the quality of medical services given to all
patients.
c) Assuring that at least one physician practicing at the
clinic shall have admitting privileges to a general
acute care hospital or a plan, as approved by ADP, f
or ensuring needed hospital services. For narcotic
treatment programs, this requirement is the
responsibility of the program sponsor and shall be
met by the program sponsor entering into an
Page 21 of 28
Last updated: 8/28/2015
Completed?
Yes
No
N/A
☐
☐
☐
☐
☐
☐
Notes
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
agreement with a hospital official to provide general
medical care34
d) Assuring that a physician has assumed medical
responsibility for all patients treated by the clinic35
3. Documentation of assumption of medical responsibility
shall include, but not be limited to, written approval of
the treatment plan36
B. Clinic Director
Completed?
Yes
No
N/A
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes
The clinic staff, professional and nonprofessional, shall be
under the administration of the clinic director
C. Substance Abuse Professional
1. Each substance abuse clinic shall have one or more
substance abuse professionals
2. A substance abuse professional is defined as a
person who has completed an Associate of Arts
degree and one year of experience, or has three
years’ experience in a mental health or substance
abuse setting. Experience in a mental health or
substance abuse field may be substituted for the
degree requirement on a year-for-year basis provided
that the experience includes clinical evaluation,
treatment planning, and individual and group
counseling.
34
Title 9, CCR, Section 10340
35
Title 9, CCR, Section 10110
36
Title 22, CCR, Section 51341.1 (h)(2)(A), or for narcotic treatment programs, Title 9, CCR, Section 10305, as specified in Title 22, CCR, Section
51341.1(h)(2)(B)
Page 22 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
3. A substance abuse professional shall provide the
following medically necessary, clinical services
prescribed for patients admitted, registered, or
accepted for care by the clinic:
a) Individual and group counseling
b) Crisis intervention37
c) Collateral services38
C. Substance Abuse Professional
4. A substance abuse professional shall document and
review client progress, prepare treatment and
discharge plans and discharge summaries
C. Minimum Staff Requirements
Completed?
Yes
☐
No
☐
N/A
☐
☐
☐
☐
☐
☐
☐
Notes
Each clinic shall be staffed by a medical director, clinic
director, and substance abuse professional. If qualified, one
person may serve in all three positions--medical director,
clinic director, and substance abuse professional. The staff
may also include other qualified professionals and
counselors39 which may include
37
Crisis Intervention is a face-to-face contact with a beneficiary in crisis. Services shall focus on alleviating crisis problems, not those already in the
Treatment Plan of Care, such as a an actual relapse or an unforeseen event or circumstance, which presents to the beneficiary an imminent threat of
relapse. Crisis intervention services shall be limited to stabilization of the beneficiary's emergency situation.
A therapist means a psychologist licensed by the California Board of Psychology; a clinical social worker or marriage and family therapist licensed by the
California Board of Behavioral Sciences; an intern registered with the California Board of Behavioral Sciences or the California Board of Psychology; a
physician.
38
Collateral Services is a face-to-face session with therapists or counselors and significant persons in the life of a beneficiary, personal, not professional
relationships focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary's treatment goals. Per Section
51341.1(b)(4). The beneficiary does not have to attend.
39
Counselor may mean any of the following: A Certified AOD Counselor as defined in Section 13005(a)(2) of Title 9 CCR. A Registrant as defined in
13005(a)(8) of Title 9 CCR.
Page 23 of 28
Last updated: 8/28/2015
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
Completed?
Yes
No
N/A
psychiatric technicians, registered nurses, licensed vocational
nurses, nurse practitioners, physician's assistants, or other
non-physician practitioners. Narcotic treatment programs
shall be staffed by a licensed nurse or other individual
lawfully
authorized to administer medication.
D. Clinic Staff
☐
☐
☐
Clinic staff shall furnish the services prescribed for patients
admitted for care by the clinic. The clinic staff shall be
qualified in accordance these standards and current legal,
professional, and technical standards, and appropriately
licensed, registered,
or certified where required
PHARMACEUTICAL SERVICE REQUIREMENTS
A. Orders for Drugs
☐
☐
☐
☐
☐
☐
☐
☐
☐
No drugs shall be administered except upon the order of a
person lawfully authorized to prescribe for and treat human
illness. All such orders shall be in writing and signed by the
person giving the order. The name, quantity or duration
of therapy, dosage, and time of administration of the drug, the
route of administration if other than oral, and the site of
injection when indicated shall be specified. Prescription
orders may be given by telephone to a licensed pharmacist,
licensed nurse, registered nurse, or licensed psychiatric
technician and shall be immediately recorded in the patient's
health record. The prescription order shall be signed by the
prescriber within 72 hours.
B. Labeling and Storage
1. Containers with are cracked, soiled or without secure
closures shall not be used. Drug labels must be legible.
2. All drugs obtained by prescription shall be labeled in
compliance with state and federal laws governing
Page 24 of 28
Last updated: 8/28/2015
Notes
CERTIFICATION STANDARDS
Federal and State Criteria & What the Agency Must Do
Guideline for Certification
Reviews/Visits
prescription dispensing. No person other than a
pharmacists or physician shall alter any prescription
label.
3. Non-legend drugs shall be labeled in conformance with
state and federal food and drug laws.
4. Test reagents, germicides, disinfectants and other
household substances shall be stored separately from
drugs.
5. External use drugs in liquid, tablet, capsule or powder
form shall be stored separately from drugs for internal
use.
6. Drugs shall be stored at appropriate temperatures
based on the manufacturer’s product insert. When
drugs are stored in the same refrigerator with food, the
drugs shall be kept in a closed, properly labeled
container clearly labeled "DRUGS."
7. Drugs shall be stored in an orderly manner in cabinets,
drawers, or cards of sufficient size to prevent crowding.
8. Drugs shall be accessible only to personnel designated
in writing by the clinic director.
9. Drugs shall not be kept in stock after expiration date on
the labels and no contaminated or deteriorated drugs
shall be available for use.
10. The drug of each client shall be kept and stored in
their original individual received containers. No drug
shall be transferred between containers, with the
exception of take-home bottles.
C. Disposal of Drugs
Disposal of drugs shall meet all applicable state and federal
requirements.
1. Drugs shall be administered as prescribed and shall be
recorded in the client’s health record
2. Drugs shall be administered only by those persons
lawfully authorized to do so.
Page 25 of 28
Last updated: 8/28/2015
Completed?
Yes
No
N/A
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Notes
Milestone Activity
Assessment
Activities and Timing
Assessments shall be completed and signed by Contractor’s staff within 30 days from the date of client’s entry into the program.
Evaluation or analysis of the cause or nature of the disorder(s) listed using DSM codes: Mental, Emotional, Psychological,
Behavioral and Substance Abuse.
Perinatal
Assessment
These also include a physical examination and laboratory testing by staff lawfully authorized to provide such services.
Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy
Must have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy.
Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy
Admission
Medical Necessity
Treatment Plan
Development*
Eligibility ends on the last day of the month in which the 60th day occurs
Admission to treatment date means the first date of the first face-to-face treatment service rendered by the provider to the
beneficiary.
The physician shall document the basis for the DSM code diagnosis indicating medical necessity in the beneficiary’s record
within 30 calendar days of the beneficiary’s date of admission to treatment.
The therapist/counselor shall complete, sign and date the initial treatment plan within 30 calendar days of the admission to
treatment date.
The beneficiary shall review, approve, sign and date the initial treatment plan, indicating whether the beneficiary participated in
preparation of the plan, within 30 calendar days of the admission to treatment date.
Physical
Examination
ODF Intervention
The physician shall review the initial treatment plan to determine whether the services are medically necessary, sign, and date
the initial treatment plan within fifteen calendar days of signature by the therapist or counselor.
If the Beneficiary has not had a physical examination within the twelve month period prior to the date of admission, a goal that
the Beneficiary have a physical examination must be added to the treatment plan.
If documentation of a Beneficiary’s physical examination, which was performed during the prior twelve months, indicates a
significant medical illness, a goal that the Beneficiary obtain appropriate treatment for the illness must be added to the
treatment plan.
Interventions, including a minimum of two provider/beneficiary contacts per 30 day period and two group counseling
sessions40 shall be provided ongoing between plan development and discharge.
40
This requirement may be waived by the physician if: Fewer contacts are clinically appropriate; or the Beneficiary is making progress towards treatment
plan goals. Exceptions must be noted, signed and dated by the physician in the Beneficiary’s record
Page 26 of 28
Last updated: 8/28/2015
ODF Progress Notes
DCH/Perinatal
Residential
Progress Notes
Individual Counseling limits exist for ODF are as follows: Intake/Assessment; Treatment Planning; Discharge Planning;
Collateral and Crisis.
Counselor/therapist must legibly print, sign and date the progress notes. Provider may not pre-date any documents.
For each Individual and Group Counseling session the therapist or counselor who conducted the counseling session shall
record a progress note for each beneficiary who participated within seven calendar days of the session that includes the
following:
 The topic of the session
 A description of the beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals
 Information on the beneficiary's attendance, including the date, start and end times of each individual and group
counseling session.
o Provider staff may not sign beneficiary names onto any document or sign-in sheet.
Counselor/therapist must legibly print, sign and date the progress notes. Provider may not pre-date any documents.
At minimum, one progress note, per calendar week, should be recorded for each beneficiary and should include:
 A description of the beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals
 A record of the beneficiary's attendance at each counseling session including the date, start and end times and topic of the
counseling session
o Provider staff may not sign beneficiary names onto any document or sign-in sheet.
Update of Treatment The therapist/counselor shall complete, sign and date the updated treatment plan no later than 90 calendar days after signing
Plan and Intervention the initial treatment plan, and no later than every 90 calendar days thereafter (unless a change in problem identification or focus
of treatment occurs)
The beneficiary shall review, approve, sign and date the updated treatment plan, indicating whether the beneficiary participated
in preparation of the plan within 30 calendar days of signature by the therapist or counselor.
ODF, DCH, Perinatal
Residential &
Naltrexone
Continued Treatment
The physician shall review each updated treatment plan to determine whether the services are medically necessary and sign
and date the updated treatment plan within fifteen calendar days of signature by the therapist or counselor.
No sooner than five months and no later than six months after admission, or the completion of the most recent justification, the
need for continued treatment must be determined by the physician.
The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s:
 Personal, medical and substance use history
 Most recent physical exam
 Treatment plan goals
 Progress in treatment (progress notes)
 Therapist/counselor recommendations
Page 27 of 28
Last updated: 8/28/2015
Discharge Plan
 Prognosis
Discharge Plans must be completed in the 30 calendar days prior to the last face-to-face treatment session on all beneficiaries
by the therapist/counselor.
Discharge of a beneficiary from treatment may occur on Voluntary or Involuntary Bases. An Involuntary Discharge is subject to
the requirements as follows: A therapist or counselor shall complete a Discharge Plan for each beneficiary, except for a
beneficiary with whom the provider loses contact. The Discharge Plan shall include, but not be limited to the following:
 A description of each of the beneficiary's relapse triggers and a plan to assist the beneficiary to avoid relapse when
confronted with each trigger.
 A Support Plan - A list of individuals and/or organizations and activities that can provide support and assistance to a
Beneficiary to maintain sobriety.
Discharge/Discharge
Summary
The Discharge Plan shall be prepared within 30 calendar days prior to the date of the last face-to-face treatment with the
beneficiary. During the therapist or counselor's last face-to-face treatment with the beneficiary, the therapist or counselor and
the beneficiary shall type or legibly print their names, sign and date the Discharge Plan.
If the beneficiary does not attend treatment for more than 30 days, the provider must discharge the beneficiary.
The provider shall complete a Discharge Summary for all beneficiaries with whom the provider has lost contact, in accordance
with all of the following requirements:
For Outpatient Drug Free, Day Care Habilitative, Perinatal Residential, and Naltrexone Treatment, the provider shall complete
the Discharge Summary within 30 calendar days of the date of the provider's last face-to-face treatment contact with the
beneficiary.
The Discharge Summary shall include all of the following:
 The duration of the beneficiary's treatment as determined by the dates of admission to and discharge from treatment;
 The reason for discharge; A
 narrative summary of the treatment episode;
 The beneficiary's prognosis.
* Treatment Plan Development shall be individualized, based on information obtained during the intake and assessment process. Treatment
Planning shall engage the beneficiary to meaningfully participate in the preparation of the initial treatment and updated treatment plans.
Beneficiaries must sign. If the beneficiary refuses to sign, staff must document the strategy used to engage beneficiary. The Treatment
Plan shall be legible, include staff names, names of counselors, therapists, physicians and be signed and dated.
Page 28 of 28
Last updated: 8/28/2015
Substance Use Disorder Treatment Provider Manual
Appendix C – DHCS Substance Use Disorder Modality Matrix
39
Service Component
Provider Type
Intensive Outpatient
Treatment
Naltrexone
Treatment
Narcotic Treatment
Program
Outpatient Drug
Free Treatment
Residentially Based
Substance Use
Disorder Services
Intake (Admission & Assessment) 3
Diagnosis of
substance use
disorders utilizing
the current DSM and
assessment of
treatment needs for
medically necessary
treatment services.
Approval of a
treatment plan by a
physician licensed in
the State of
California. This may
include a physical
examination and
laboratory testing
(e.g., body specimen
screening) necessary
for treatment and
evaluation
conducted by staff
lawfully authorized
to provide such
services and/or order
laboratory.
Collection of
information for
assessment used
in the evaluation
and analysis of
the cause or
nature of the
substance use
disorder which
includes
exploration of
relevant mental,
emotional,
psychological
and behavioral
problems that
may be
contributing to
the substance
use disorder.
L1
C2
Group Counseling
Individual
Counseling
Face-to-face
Face-to-face contacts in
contacts between
which one or more
therapists or counselors a beneficiary and a
therapist or
treat two or more
clients at the same
counselor.
time, focusing on the
Telephone
needs of the individuals
contacts, home
served.
visits, and
For outpatient drug
hospital visits
free treatment services shall not qualify
and narcotic treatment
as Medi-Cal
programs, group
reimbursable
counseling shall be
units of service.
conducted with no less
than four and no more
than 10 clients at the
same time, only one of
whom needs to be a
Medi-Cal beneficiary.
Patient
Education
A learning
experience using a
combination of
methods such as
teaching,
counseling, and
behavior
modification
techniques which
influence patients'
knowledge and
health and illness
behavior.
Medical
Psychotherapy
Medication
Services
Type of
The prescription
counseling service or administration
consisting of a
of medication
face-to-face
related to
discussion
substance use
conducted by the
treatment
medical director
services, or the
of the Narcotic assessment of the
Treatment
side effects or
Program on a
results of that
one-to-one basis
medication
with the patient.
conducted by
staff lawfully
authorized to
provide such
services and/or
order laboratory
testing within the
scope of their
practice or
licensure.
Transportation
Services
Provision of or
arrangement for
transportation to
and from
medically
necessary
treatment.
This may also
include health
questionnaires.
L1
C2
L1
C2
L1
C2
L1
L1
C2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Collateral
Services
Crisis Intervention
Services
Face-to-face
Face-to-face contact
sessions with
between a therapist or
therapists or
counselor and a
counselors and
beneficiary in crisis.
significant
Services shall focus
persons in the life on alleviating crisis
of a beneficiary,
problems. “Crisis”
focusing on the
means an actual
treatment needs
relapse or an
of the beneficiary unforeseen event or
in terms of
circumstance which
supporting the
presents to the
achievement of
beneficiary an
the beneficiary's
imminent threat of
treatment goals.
relapse. Crisis
Significant
intervention services
persons are
shall be limited to
individuals that
stabilization of the
have a personal,
beneficiary's
not official or
emergency situation.
professional,
relationship with
the beneficiary.
L1
C2
L1
C2
Treatment Planning*
The provider shall
prepare an
individualized written
treatment plan, based
upon information
obtained in the intake
and assessment process.
The treatment plan
includes: problems to be
addressed, goals to be
reached which address
each problem, action
steps which will be
taken by the provider
and/or beneficiary to
accomplish identified
goals, target dates for
accomplishment of
action steps and goals,
and a description of
services, including the
type of counseling to be
provided and the
frequency thereof. The
treatment plan may also
include medical.
L1
C2*
Discharge
Services*
The process to
prepare a person for
the post treatment
return or reentry
into the community,
and the linkage of
the individual to
essential community
treatment, housing
and human services.
L1
C2*
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
S
X
X
X
X
X
X
SOURCE: DHCS SUD Services Chart – California State Plan, Attachment 3 – Services, Supplement 3 to Attachment 3. 1-B
1 Licensed providers must meet the following qualifications: MD, PA, NP, RN, Psy. D, LCSW, MFT or Intern registered by Board of Psychology or Behavioral Science Board and supervised by a mental health professional.
2 Certified providers must meet the following qualifications: Counselors or registrants certified by an organization who will have 155 hours of formal Education; 160 hours of supervised AOD training; 2,080 hours of work experience in AOD counseling; obtain at least 70% score on
a written or oral examination approved by the certifying organization and complete 40 hours of continuing education every two years in order to retain certification.
3 The process of admitting a beneficiary into a Substance Use Disorder Treatment Program. Intake includes the evaluation or analysis of substance use disorders; the diagnosis of substance use disorders; the assessment of treatment needs to provide
and assistance with accessing community and human services networks. Intake may include a physical examination and laboratory testing necessary for substance use disorder treatment.
* Certified personnel may assist with some aspects of this service, however, a licensed provider is responsible for this service component.
S - Safeguarding Medication; assistance with resident's self-administration of medication
40
medically necessary services;
Appendix D – Substance Use Disorder Treatment Services by Modality
Outpatient Drug Free Treatment
Outpatient Drug Free (ODF) Treatment is provided to clients who have a substance use disorder
diagnosis prescribed by a physician as medically necessary. These services are offered in a
community outpatient setting and include:







Intake
Individual and Group Counseling
Patient Education
Medication Services
Collateral Services
Crisis Intervention
Treatment Planning and Discharge Services
Individual counseling is provided only for the purposes of intake, crisis intervention, collateral
services, and treatment and discharge planning. Each ODF clients must receive at least two group
face-to-face counseling sessions every thirty days. Groups may range in size from 4 to 10
participants, at least one of which must be a Medi-Cal beneficiary. Group sessions focus on shortterm personal, family, job/school and other challenges and their relationship to substance use.
Reimbursable group sessions may last up to 90 minutes.
Day Care Habilitative
Day Care Habilitative treatment counseling services must be provided to clients for a minimum of
three hours per day, three days a week and include:







Intake
Individual and Group Counseling
Patient Education
Medication Services
Collateral Services
Crisis Intervention Services
Treatment Planning and Discharge Services
Narcotic Treatment Program
The Narcotic Treatment Program uses methadone (or levoalphacetylmethadol if available and
prescribed) as a narcotic replacement drug to alleviate the symptoms of withdrawal from opioids.
Each client must receive a minimum of fifty minutes of face-to-face counseling sessions with a
therapist or counselor for up to 200 minutes per calendar month. Additional services may be
provided based on medical necessity. Components of the Narcotic Treatment Program include:








Intake
Individual and Group Counseling
Patient Education
Medical Psychotherapy
Medication Services
Collateral Services
Crisis Intervention
Treatment Planning and Discharge Services
41
Naltrexone Treatment
Naltrexone is a medication provided as an outpatient treatment service to serve clients who have
detoxified after using opioids. Naltrexone clients must receive at least two face-to-face
counseling sessions with a therapist or counselor every 30-day period. The intake assessment to
admit a patient into the program is the same as for the Narcotic Treatment Program. Service
components include:







Intake
Individual and Group Counseling
Patient Education
Medication Services
Collateral Services
Crisis Intervention Services
Treatment Planning and Discharge Services
Residentially Based Substance Use Disorder Treatment
Residentially Based Substance Use Disorder Treatment is a non-institutional, non-medical,
residential program that provides rehabilitation services to clients, including pregnant and
postpartum women, with a substance use disorder diagnosis. Services must include womenspecific treatment and recovery services for pregnant and postpartum women. Each client
shall live on the premises and shall be supported in their efforts to restore, maintain, and apply
interpersonal and independent living skills and access community support systems. Services
are provided in a 24-hour structured environment and covered under the Drug Medi-Cal
program when medically necessary. Medically necessary rehabilitative services are provided
in accordance with an individualized client plan prescribed by a licensed physician. The cost
of room and board are not reimbursable under the Medi-Cal program. Components of
Perinatal Residential Substance Use Disorder Treatment include:







Intake (once per admission)
Individual and Group Counseling (a minimum of two sessions per 30-day period)
Patient Education (varies according to the needs of the client)
Collateral Services (as needed)
Crisis Intervention Services (as needed)
Treatment Planning (upon admission and every 90 days thereafter)
Discharge Services (once per admission)
In addition, services must include transportation to and from medically necessary treatment.
Facilities also must safeguard medication by storing all resident medication and facility staff
members assisting residents with self-administration of medication.
42
Appendix E - Individual Client Record Data Set List
Following is a list of the minimum data sets that must be entered, maintained, and updated as
necessary for each client admitted to treatment and receiving services. Each client record must be
maintained for at least three years following the last face-to-face contact with the client, or if an
audit is in progress, until the audit is completed. Note that these required data sets reflect DMC
requirements; your program may have additional documentation and retention requirements.
I.
Demographic of Personal Information:
 Client Identifier (i.e. name, number)
 Client Date of Birth
 Client Gender
 Client Race/Ethnicity
 Client Address
 Client Telephone Number
 Client Next of Kin or Emergency Contact (include phone number)
 Medical Documentation Substantiating Client Pregnancy and Last Day of Pregnancy (for
pregnant and postpartum women clients only)
II.
Treatment Episode Information (all activities, services, sessions, and assessments)
 Intake and Admission Data (including Health Questionnaire, and, if applicable, Physical
Examination)
 Treatment Plan (see Narcotic Treatment Program note on next page):
1. Statement of problem(s) to be addressed in treatment;
2. Goal(s) to be reached addressing each problem(s);
3. Action steps which will be taken by provider and/or client to accomplish identified
goal(s);
4. Target date(s) for accomplishment of action step(s) and goal(s);
5. Description of services including the type and frequency of counseling to be provided
including a specific number of sessions over a specific period of time for group
counseling and for individual counseling, it must be on the treatment plan;
6. Assignment of a primary therapist or counselor;
7. DSM-5 code diagnosis; and
8. Physical examination goal (for clients with no physical exam in 12 months prior to
admission) and treatment goal for clients with significant medical illness(es) as
documented by physical examination in 12 months prior to admission or within 30
calendar days of treatment admission date.
 Client Contacts
 Client Services (services tied to client treatment plan)
 Progress Notes (notes directly linked to client progress toward treatment goals)
 Continuing Services Justification
 Laboratory Test Orders and Results (i.e. urine surveillance)
 Referrals (referrals tied to client treatment plans)
 Counseling Notes
 Discharge Plan
 Discharge Summary
 Evidence of Compliance with Requirements for Specific Treatment Services
 Evidence of Compliance with Multiple DMC Billing Requirements
 Other Information Relating to Treatment Services Provided to Client
Narcotic Treatment Programs
Narcotic Treatment Programs must comply with treatment plan documentation requirements that
are similar to those for other treatment modalities. Current DHCS regulations require NTP
providers to comply with requirements for initial and updated treatment plans that are found in
Section 10305, Title 9, CCR including:
 A statement of client needs to be addressed including a summary of client’s initial
psychological and sociological background including education and vocational experience,
health care, employment, education, psychosocial, vocational rehabilitation, economic, and
legal services;
 Short-term goals (less than 90 days to achieve) and long-term goals (specified time of
greater than 90 days to achieve) to be achieved by the client based on needs identified;
 Target dates for the accomplishment of short-term and long-term goals;
 Specific behavioral tasks that will be taken by the client to complete each short-term and
long-term goal;
 A description of the type and frequency of counseling services to be provided to the client;
and
 An effective date based on the day the primary counselor signed the initial treatment plan.
Given the SFHN-BHS goal to create a seamless treatment system for all clients regardless of where
they seek treatment services, DPH DMC NTP providers will be required to document all treatment
plan elements required of other treatment modality providers in addition to Section 10305, Title 9,
CCR requirements.
44
Appendix F – Sample Compliance Audit Tool
1
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004); DPH = S.F. Department of Public Health; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of
Regulations, Title 9 - Narcotic Treatment Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal
Compliance Ratings
Y = Yes; N I=ofNeeds
Improvement;
= Immediate
Action; NA = Not Applicable
S.F.Key:
Department
Public
Health * IA
Office
of Compliance
Substance Use Disorder Treatment Provider Compliance Audit
Date of Review: _______________________________________
Review for County Fiscal Year: 20___ - ___
Provider Name: __________________________________________
Provider DMC Certified? □ Yes
□ No
Modality of Service (check all that apply):
□ Day Care Habilitative
□ Narcotic Treatment Program
□ Residential - Perinatal?: □ Yes
□ Outpatient Drug Free
□ Naltrexone
□ No
DPH Compliance Officer(s): __________________________________________________________________________________________
Contact Information: Email: _______________________________________________________________________
Phone: _______________________________________________________________________
DPH Compliance Officer(s):
____________________________________
_____________________________________
Signature
_____________________________________
Print Name
Provider Representative(s):
____________________________________
_____________________________________
Print Name
_____________________________________
Signature
____________________________________
Print Name
____________________________________
_____________________________________
Print Name
_____________________________________
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
Compliance Review Section
1. Client Individual Patient Records
- The provider establishes an individual client record for each client
admitted to the program?
- All client individual records include all of the following client
personal information:
 Client identifier (e.g. name, number);
 Client date of birth, gender, and race and/or ethnicity;
 Client address and telephone number; and
 Client next of kin or emergency contact; plus
 For pregnant and postpartum women, medical documentation
substantiating client’s pregnancy and last day of pregnancy.
- All client individual records include all of the following client
treatment episode info & documentation of reimbursed services?
Regulatory
Authority
Y
NI IA
NA
DTS II.C.1
Title 9 §10160
Title 22
§51341.1(g)(1)(A)
□
□ □
□
DTS II.C.2.a
Title 9 §10165
Title 22
§51341.1(g)(1)(A)
□
□ □
□
DTS II.C.2.b thru f
Title 9 §10165, 10310,
10360
Title 22 §51341.1(g)(1)(B)
□
□ □
□
Compliance Findings/Notes
 Intake and admission data (including, if applicable, a physical
examination);
 Completed DPH Health Questionnaire;
 Initial and updated treatment plans with required review, approvals,
type/legibly printed names, signatures, and dates;
 Evidence of compliance with provider and client contact requirements
for treatment modalities or a written and signed determination by a
licensed physician that fewer client contacts are appropriate and the
client is progressing toward treatment plan goals;
 Progress notes;
 Continuing services justifications;
 Laboratory test orders and results;
 Referrals;
 Counseling notes;
 Discharge plan;
 Discharge summary (for lost contacts/involuntary discharges);
 Evidence of compliance with multiple billing requirements;
 Evidence of compliance with specific treatment modality service
requirements (Title 22 §51341.1(d)); and
 Any other information relating to services claimed for reimbursement.
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
2
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
1. Client Individual Patient Records continued
Regulatory
Authority
Y
NI
IA
NA
-
All client records are written legibly in ink or typed?
DTS II.C.2 f
Title 22§51341.1(g)(1)
□
□ □
□
-
All client record entries are signed and dated?
DTS II.C.2.bf
Title 22 §51341.1(g)(1)
□
□ □
□
DPH/HIPAA
Requirement
□
□ □
□
Title 22
§51341.1(h)(1)(A)(v)
□
□ □
□
Title 22
§51341.1(h)(1)(A)(v)
□
□ □
□
Title 22
§51341.1(h)(1)(A)(v)
□
□ □
□
Title 22
§51341.1(h)(1)(A)(vi)
□
□ □
□
2. Client Individual Patient Record Retention
- All of the documentation in the client’s individual client record is
maintained for a minimum of 7 years from the date of the last faceto-face contact between the client and provider?
3. Intake & Admission: DSM 5 Diagnosis
- All clients meet admission criteria as evidenced by a client DSM 5
substance use disorder diagnosis written in the client record?
- A licensed physician, therapist, physician assistant or nurse
practitioner has evaluated each client to diagnose whether clients
have a substance use disorder within 30 calendar days of the client’s
admission to treatment date as evidenced by a written basis for the
diagnosis in the client’s individual patient record that is legible,
signed and dated?
- Where a licensed physician did not determine the client DSM 5
substance use disorder diagnosis, a licensed physician has reviewed
and approved each client’s diagnosis as evidenced by a physician’s
legibly printed or typed name, signature and date in a client’s
treatment plan?
4. Intake & Admission: Medical Necessity
- All clients meet medical necessity requirements as evidenced by a
written and dated justification by a licensed physician in the client’s
individual patient record within 30 calendar days of a client’s
admission/readmission to treatment date?
Compliance Findings/Notes
2
3
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
3
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
4
5. Intake & Admission: Additional Requirements
Regulatory
Authority
Y
NI
IA
NA
DTS II.A.2
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
- Conducts initial interview with client to determine whether admission
eligibility criteria are met?
Title 22§51341.1 (h)
- Documents how client meets admission criteria in client record?
Title 22 §51341.1 (h)
- Documents personal, medical and substance us history at intake
including, at a minimum:
Title 22§51341.1 (h)
DTS II.A.2.c
DTS II.A.2.d
DTS II.A.2.d
 Social, economic, and family background?
Title 22§51341.1 (h)
 Education?
Title 22 §51341.1 (h)
 Vocational achievements?
Title 22 §51341.1 (h)
 Criminal history and legal status?
Title 22 §51341.1 (h)
 Medical history?
Title 22 §51341.1 (h)
 Drug history?
Title 22 §51341.1 (h)
 Previous treatment?
Title 22 §51341.1 (h)
DTS II.A.2.d
DTS II.A.2.d
DTS II.A.2.d
DTS II.A.2.d
DTS II.A.2.d
DTS II.A.2.d
DTS II.A.2.e
- Obtains client consent after completion of intake/admission process?
Title 22 §51341.1 (h)
- Completes DPH Health Questionnaire for all clients?
DPH Requirement
- Conducts a health assessment within 30 calendar days from admission
to treatment date that includes a physical examination by a physician,
nurse practitioner, or physician’s assistant?
Title 22 §51341.1 (h)
- Documents health assessment in client record?
Title 22 §51341.1 (h)
- Determines client need for physical or laboratory examinations (by a
licensed physician)?
Title 22 §51341.1 (h)
DTS II.A.3.a
DTS II.A.3
DTS II.A.3.b
Compliance Findings/Notes
5
6
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
4
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
5. Intake and Admission: Additional Requirements continued
For DMC Programs:
Licensed Physician Review of Client History
- A physician reviews each client’s personal, medical and substance use
history within 30 calendar days of the client’s admission to treatment
date as evidenced by documentation in the client individual patient
record and the legibly printed or typed name, date and signature of a
physician?
Physical Examination Requirements
- A licensed physician reviews the client’s most recent physical
examination within 30 calendar days of client’s admission to
treatment date for clients who have had a physical examination within
the twelve-month period prior to admission to treatment date as
evidenced by documentation in the client’s individual patient record?
- When the provider has not been able to obtain documentation of a
client’s most recent physical examination, there is written
documentation in the client’s individual patient record of efforts made
to obtain the documentation on the client’s behalf?
- Where a physician, registered nurse practitioner, or physician’s
assistant performs a physical examination of the client within 30
calendar days of the client’s admission to treatment date, there is
written documentation of findings within the client’s individual patient
record?
- Where there is no physical examination documentation or an
examination performed by a physician, registered nurse practitioner or
physician’s assistant, there is a goal incorporated within the initial and
updated treatment plans of obtaining a physical examination until the
exam goal has been met?
- Where a client’s physical examination in the past 12 months indicates
a client has a significant medical illness, there is evidence of a goal in
the treatment plan that the client obtain appropriate treatment for the
illness?
Regulatory
Authority
Y
NI
IA
NA
Title 22
§51341.1(h)(1)(A)(iii)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Title 22
§51341.1(h)(1)(A)(iv)(a)
through (c)
Title 22
§51341.1(h)(2)(A)(i)(h)(i)
Compliance Findings/Notes
7
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
5
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
Regulatory
Authority
Y
NI
IA
NA
For Naltrexone Treatment Services:
- Provider documents client has a documented history of opiate
addiction as evidenced by documentation in client individual patient
record?
Title 22
§51341.1(h)(1)(B)(i)(a)
□
□
□
□
- Provider confirms client is at least 18 years of age as evidenced by
documentation in client individual patient record?
Title 22
§51341.1(h)(1)(B)(i)(b)
□
□
□
□
- Provider confirms client has been opiate free for a period of time to be
determined by a physician based on the physician’s clinical judgement
as evidenced by documentation in client individual patient record?
- Provider administers a body specimen to confirm opiate free state of
each client as evidenced by documentation in client individual patient
record?
Title 22
§51341.1(h)(1)(B)(i)(c)
□
□
□
□
Title 22
§51341.1(h)(1)(B)(i)(d)
□
□
□
□
Title 9 §10270
Title 9 §10305
□
□
□
□
DMC Organized Delivery
System Waiver
□
□
□
□
5. Intake and Admission: Additional Requirements continued
- Provider confirms client is not pregnant and is discharged from the
treatment if client becomes pregnant as evidenced by documentation in
client individual patient record?
For Narcotic Treatment Programs:
- Initial treatment plan includes strategies to assist clients in
understanding substance use and how to reduce harm associated with
substance use?
- Medical director has conducted a medical evaluation consisting of at a
minimum a medical history that includes a history of client’s illicit
drug use; lab tests for determination of narcotic drug use, tuberculosis,
infectious diseases, and syphilis; and a physical examination as
specified under Title 9 §10270 as evidenced by written documentation
in the client’s individual patient record?
- Medical director has documented the evidence used in the medical
evaluation to determine physical dependence and addition to opiates?
For Residential:
- Program administers the American Society for Addiction Medicine
(ASAM) Multidimensional Assessment as evidenced by written
documentation in individual patient record?
Compliance Findings/Notes
8
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
6
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
6. Initial Treatment Plan
For nonresidential programs:
- Develops initial individual treatment plan for each client within 30
calendar days from the client’s admission to treatment date which
includes all of the following at minimum:
Regulatory
Authority
Y
NI
IA
NA
DTS II.C.2.c
□
□
□
□
□
□
□
□
□
□
 Statement of challenge(s) to be addressed in treatment?
DTS II.C.2.c
 Statement of goal(s) to be reached which address the challenge(s)?
DTS II.C.2.c
□
□
 Action steps which will be taken by the program and/or client to
accomplish goal(s)?
DTS II.C.2.c
□
□
□
□
DTS II.C.2.c
□
□
□
□
DTS II.C.2.f
□
□
□
□
Title 22
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
 Target date(s) for accomplishment of action step(s), goal(s), and
when possible, resolution of challenge(s)?
- Initial treatment plan signed and dated by staff?
For DMC Programs:
- A description of services including the types of counseling to be
provided and the frequency thereof?
§ 51341.1(h)(2)(A)(i)
Title 22
- Assignment of a primary therapist or counselor?
§ 51341.1(h)(2)(A)(i)
- Client’s diagnosis?
§ 51341.1(h)(2)(A)(i)
- Goal to have a physical examination if client has not had a physical
exam within the 12-month period prior to the admission to treatment
date?
- Goal to obtain appropriate treatment for significant medical illness
documented on a physical examination of the client that was
performed during the 12 months prior to the admission to treatment
date?
- Therapist or counselor completes, types or legibly prints name, and
signs and dates the initial treatment plan within 30 calendar days of
the admission to treatment date?
Title 22
Title 22
§ 51341.1(h)(2)(A)(i)
Title 22
§ 51341.1(h)(2)(A)(i)
Title 22
§51341.1(h)(2)(A)(ii)
Compliance Findings/Notes
9
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
7
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
6. Initial Treatment Plan continued
- Client review and approval of initial treatment plan with typed or
legibly printed name, signature and date within 30 calendar days of
the admission to treatment date?
- If client refuses, documentation of reason for refusal to sign the
treatment plan and strategy to engage the client to participate in
treatment?
- Physician reviews initial treatment plan for medical necessity and type
or legibly print their name, and sign and date the treatment plan within
15 calendar days of the signature by the therapist or counselor?
For short-term residential (program duration 30 days or less):
- Develops individual treatment plan for each client within 14 calendar
days from the client’s admission to treatment date with required
elements?
- Uses ASAM Multidimensional Assessment in developing treatment
plan as evidenced by ASAM findings in client individual patient
record?
For long-term residential (program duration 31 days or more):
- Develops individual treatment plan for each client within 14 calendar
days from the client’s admission to treatment date with required
elements?
- Uses ASAM Multidimensional Assessment in developed treatment
plan?
For Narcotic Treatment Programs:
- Develops an individualized initial maintenance treatment plan within
28 calendar days after the initiation of maintenance treatment?
- Includes short-term goals (those requiring 90 days or less for client to
achieve); long-term goals (those exceeding 90 days for client to
achieve); specific behavioral tasks clients must accomplish to compete
each goals; a description go the type an frequency of counseling
services to be provided; and an effective date based on the day the
primary counselor signs the initial treatment plan?
- Supervising counselor reviews and signs initial maintenance treatment
plan within 14 calendar days from effective date?
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
Regulatory
Authority
Y
NI
IA
NA
Title 22
□
□
□
□
□
□
□
□
□
□
□
□
DMC Organized
Delivery System
Waiver
□
□
□
□
AOD Cert. Stds.
12070
□
□
□
□
DMC Organized
Delivery System
Waiver
□
□
□
□
Title 9 §10270
□
□
□
□
Title 9 §10270
□
□
□
□
Title 9 §10270
□
□
□
□
§51341.1(h)(2)(A)(ii)
Title 22
§51341.1(h)(2)(A)(ii)
AOD Cert. Stds.
12070
Compliance Findings/Notes
8
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
6. Initial Treatment Plan continued
- Medical director reviews initial maintenance treatment plan and needs
assessment and signs within 14 calendar days from the effective date
and makes amendments to the plan where medically deemed
appropriate?
Regulatory
Authority
Y
NI
IA
NA
Title 9 § 10270
□
□
□
□
Compliance Findings/Notes
0
1
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
9
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
7. Treatment Plan Review and Updates
For nonresidential programs:
- Staff reviews and documents client’s progress in achieving treatment
plan objectives within 30 days of signing the initial treatment plan and
no later than 30 days thereafter?
For short-term residential (program duration 30 days or less):
- Staff reviews and documents client’s progress in achieving treatment
plan objectives within 10 calendar days after signing the initial
treatment plan and not later than every 10 days thereafter?
- Uses ASAM Multidimensional Assessment in assessing client progress
on treatment plan goals?
For long-term residential (program duration 31 days or more):
- Staff reviews and documents client’s progress in achieving treatment
plan objectives within 14 calendar days after signing the initial
treatment plan and no later than 14 days thereafter?
- Staff and client review and update treatment plan when a change in
problem identification or focus of treatment occurs, or no later than 90
days after signing the initial treatment plan and no later than 90 days
thereafter, whichever comes first?
- Uses ASAM Multidimensional Assessment in assessing client progress
on treatment plan goals?
- Updated treatment plans signed and dated by staff and client?
For DMC Programs:
- Therapist or counselor completes, types or legibly prints name, signs
and dates updated treatment plan no later than 90 calendar days after
signing the initial treatment plan, and no later than every 90 calendar
days thereafter, or when a change in problem identification or focus of
treatment occurs, whichever comes first?
Regulatory
Authority
Y
NI
IA
NA
AOD Cert. Stds.
12070
□
□
□
□
AOD Cert. Stds.
12070
□
□
□
□
DMC Organized
Delivery System
Waiver
□
□
□
□
AOD Cert. Stds.
12070
□
□
□
□
AOD Cert. Stds.
12070
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
DMC Organized
Delivery System
Waiver
AOD Cert. Stds.
12070
Title 22
§51341.1(h)(2)(A)(iii)
Compliance Findings/Notes
2
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
10
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
7. Treatment Plan Updates continued
- Clients review, approve, type or legibly print their name and sign and
date updated treatment plans within 30 calendar days of the signature
by the therapist or counselor?
- If client refuses to sign updated treatment plan, provider documents
reason for refusal and strategy for to engage client to participate in
treatment?
- Physicians review each updated treatment plan to determine whether
services are medically necessary?
- Physicians type or legibly print their name and sign and date updated
treatment plans within 15 calendar days of the signature of the
therapist or counselor when they determine services in updated
treatment plan are medically necessary?
For Narcotic Treatment Programs:
- Primary counselor evaluates and updates client’s maintenance
treatment plan whenever necessary or at least once every three months
from the date of admission?
- Supervising counselor reviews and signs updated client maintenance
treatment plans within 14 calendar days from the effective date?
- Medical director reviews updated client maintenance treatment plans
and signs within 14 calendar days from the effective date and makes
amendments to the plan where medically deemed appropriate (a
licensed psychologist may review for medical necessity, type or
legibly print their name and sign and date an updated treatment plan
where a physician has not prescribed medication)?
Regulatory
Authority
Y
NI
IA
NA
Title 22
□
□
□
□
Title 9 § 10270
□
□
□
□
Title 9 § 10270
□
□
□
□
Title 9 § 10270
□
□
□
□
§51341.1(h)(2)(A)(iii)
Compliance Findings/Notes
Title 22
§51341.1(h)(2)(A)(iii)
3
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
11
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
8. Progress Notes
For Outpatient Drug Free and Naltrexone Treatment:
- Therapists or counselors record a progress note for each individual or
group counseling session for each client who participates in the session
and type or legibly print their name and sign and date the progress note
within 7 calendar days of the counseling session?
- Progress notes include all of the following?
 Topic of the session?
 Type of counseling format (e.g. individual, group or medical
psychotherapy)?
 Description of client’s progress on the treatment plan challenges,
goals, action steps, objectives and/or referrals?
 Information on the client’s attendance, including the date, start and
end times of each individual and group counseling session?
For Intensive Outpatient and Perinatal Residential:
- Therapists or counselors record a minimum of one progress note per
calendar week for each client participating in structured activities
including counseling sessions and type or legibly print their name and
sign and date the progress note within the following calendar week
- Progress notes include: description of client’s progress on the treatment
plan challenges, goals, action steps, objectives, and/or referrals; record
of the client’s attendance at each counseling session including the date,
start and end times and topic of the counseling session.
Regulatory
Authority
Y
NI
IA
NA
Title 22 §51341.1(h)(3)
□
□
□
□
Title 22 §51341.1(h)(3)
□
□
□
□
□
□
□
□
□
□
□
□
Title 22§51341.1(h)(3)
□
□
□
□
Title 22 §51341.1(h)(3)
□
□
□
□
Title 22 §51341.1(h)(3)
□
□
□
□
Title 22 §51341.1(h)(3)
Title 22§51341.1(h)(3)
Compliance Findings/Notes
4
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
12
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
8. Progress Notes continued
For Narcotic Treatment Programs:
- Counselors conducting the counseling sessions document within 14
calendar days of the session including all of the following:
 Date of session?
 Type of counseling format (e.g. individual, group or medical
psychotherapy)?
 Duration of session in 10-minute intervals?
 Summary of session including one or more of the following:
Regulatory
Authority
Y
NI
IA
NA
Title 9 §10345
□
□
□
□
Title 9 §10345
□
□
□
□
Title 9 §10345
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Title 9 §10345
□
□
□
□
AOD. Cert. Stds.
13000
□
□
□
□
Title 9 §10345
Title 9 §0345
Title 9 §10345
o Patient’s progress toward goals in treatment plan?
Title 9 §10345
o Response to a drug screening specimen?
Title 9 §10345
o New issues or challenges that affect the client’s treatment?
Title 9 §10345
o Nature of prenatal support provided by the program or other
health care providers?
o Goal and/or purpose of the group session, the subjects discussed,
and a brief summary of client’s participation?
For Residential Treatment:
- Documents progress notes on a weekly basis?
Compliance Findings/Notes
5
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
13
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
9. Frequency of Services, Services Referrals and Group Counseling
Requirements
Regulatory
Authority
- Meets frequency of service requirements?
 For Outpatient Drug Free, sees clients weekly or more often
depending on his/her need and treatment plan?
 For Outpatient Drug Free, all clients participate in at least two
counseling sessions per 30-day period?
 For Day Care Habilitative, all clients provided a minimum
of three hours per day for three days per week of individual or
group sessions and/or structured therapeutic activities.
 For Residential, all clients receive minimum of 20 hours per week of
counseling and/or structured therapeutic activities?
 For Day Treatment, all clients receive a minimum of 10 hours per
week of counseling and/or structured therapeutic activities?
 Documents in client records exceptions to frequency of services for
clients where program staff have determined that fewer client
contracts are clinically appropriate and progress toward treatment
goals is being maintained?
- Assesses need for the following minimum services and provides or
makes referrals directly to an ancillary service to meet service needs:
 Education opportunity?
DTS II.B.3.a
Y
NI
IA
NA
DTS II.B.3.a
□
□
□
□
□
□
□
□
DTS II.B.3.a
□
□
□
□
AOD Cert. Stds.
13000 e
□
□
□
□
DTS II.B.3.a
□
□
□
□
DTS II.B.3.a
□
□
□
□
DTS II.B.3.a
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
DTS II.B.3.b
DTS II.B.3.b
 Vocational counseling and training?
DTS II.B.3.b
 Job referral and placement?
DTS II.B.3.b
 Legal services?
DTS II.B.3.b
 Medical services and dental services?
DTS II.B.3.b
 Social/recreational services?
 Individual counseling and group counseling for clients, spouses,
domestic partners, parents and other significant people?
- Documents service referrals in client records?
DTS II.B.3.b
DTS II.B.3.b
DTS II.B.3.b
Compliance Findings/Notes
6
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
14
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
9. Frequency of Services, Services Referrals and Group Counseling
Requirements continued
- Provides or refers clients to the following services:
Regulatory
Authority
Y
NI
IA
NA
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Title 22
§51341.1 1(h)(5)
□
□
□
□
Title 22
§51341.1 1(h)(5)
□
□
□
□
Title 22
§51341. (b)(11)
□
□
□
□
Title 9 §10345
□
□
□
□
DTS II.B.4

Emergency?
DTS II.B.4.a

Medical consulting?
DTS II.B.4.b

Medical detoxification when deemed appropriate?
DTS II.B.4.c
- Meets group size requirements for group counseling (two or more
participants)?
- Meets group counseling documentation requirements?
For DMC Programs:
- For Outpatient Drug Free clients are provided a minimum of 2
counseling sessions per 30 day period except when physician
determines fewer client contacts are clinically appropriate or the client
is progressing toward treatment plan goals?
- For Intensive Outpatient clients are provided a minimum of 3 hours of
counseling session 3 days a week except when physician determines
fewer client contacts are clinically appropriate or the client is
progressing toward treatment plan goals?
- Meets group size requirements for counseling sessions?
 No less than 2, no more than 12 clients at the same time.
- Meets confidential session setting requirements?
- Ensures client’s age 17 or younger do not participate with clients age
18 and older except at school sites?
For Narcotic Treatment Programs:
- Clients receive a minimum of 50 minutes of counseling per calendar
month except where the medical director adjusts or waives at any time
after admission by medical order the minimum number of minutes of
counseling services per calendar month along with rationale for
adjusting or waiving counseling services?
AOD Cert. Stds.
13000
AOD Cert. Stds.
13000
Compliance Findings/Notes
7
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
15
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
Regulatory
Authority
Y
NI
IA
NA
- Clients administered monthly urinalysis test/weekly for clients who are
pregnant
Title 9 § 10310
Title 9 § 10360
□
□
□
□
- Complies with multiple registration at time of admission requirements
including physician documentation of dosage?
Title 9 § 10210
□
□
□
□
- Complies with medication dosage level requirements including clients
who are pregnant?
Title 9 § 10355
Title 9 § 10360
□
□
□
□
- Complies with tuberculosis testing requirements?
Title 9 § 10567
□
□
□
□
9. Frequency of Services, Services Referrals and Group Counseling
Requirements continued
Compliance Findings/Notes
8
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
16
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
10. Continuing Services
- Therapist or counselor no sooner than 5 months and no later than 6
months after client admission to treatment dates or the date of
completion of the most recent justification for continuing services,
reviews the client’s progress and eligibility to continue to receive
treatment services and recommends whether the client should or
should not continue to receive treatment services?
For DMC Providers:
- Physician determines whether continued services are medically
necessary and documents determination in client record including
consideration of all of the following: client’s personal, medical, and
substance use history; documentation of the client’s most recent
physical examination; client’s progress notes and treatment plan goals;
and client’s prognosis?
- Client discharged when physician determined continuing treatment
services not medically necessary?
Regulatory
Authority
Y
NI
IA
NA
Title 22
□
□
□
□
□
□
□
□
§51341.1(h)(5)(A)(i)
Title 22
§51341.1(h)(5)(A)(ii)
Compliance Findings/Notes
9
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
17
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
11. Discharge Plan and Discharge Summary
- Staff completes discharge summaries for each client that include:

Description of treatment episodes or recovery services?

Current alcohol and/or other drug usage?

Vocational and educational achievements?

Legal status?

Reason for discharge and whether the discharge was involuntary
or a successful completion?

Client’s continuing recovery or treatment exit plan?

Transfers and referrals?

Client’s comments?
For DMC Programs:
- Therapists or counselors complete a discharge plan for each client
except for clients with whom the provider loses contact?
- Discharge plan prepared within 30 calendar days prior to the date of
the last face-to-face treatment with the client that includes all of the
following at a minimum:
 Description of each of the client’s relapse triggers and a plan to
assist the client to avoid relapse when confronted with triggers?

A support plan?
- Therapists or counselors and clients type or print legibly their names,
sign and date the discharge plans?
- Clients provided a copy of discharge plan by therapist or counselors at
last face-to-face treatment with client?
Regulatory
Authority
Y
NI
IA
NA
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
AOD Cert. Stds.
12085
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Title 22
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
§51341.1(h)(6)(A)
Title 22
§51341.1(h)(6)(A)
Title 22
§51341.1(h)(6)(A)
Title 22
§51341.1(h)(6)(A)
Title 22
§51341.1(h)(6)(A)
Compliance Findings/Notes
0
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
18
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
11. Discharge Plan and Discharge Summary continued
- Providers complete a discharge summary for clients with whom
contact has been lost within 30 calendar days of the date of the
provider’s last face-to-face treatment contact with the client that
includes all of the following: duration of client’s treatment; reason for
discharge; narrative summary of treatment episode; and client’s
prognosis.
For Narcotic Treatment Programs:
- Program completes a discharge summary for each client who is
terminated from treatment either voluntarily or involuntarily that
includes at a minimum: client’s name and discharge date; reason for
discharge; and summary of client’s progress during treatment.
For Residential Programs:
- Links clients to medically necessary recovery services, using
results of the ASAM Criteria Multidimensional Assessment,
Dimension 6, Recovery Environment, that may include the
following:
 Recovery Monitoring: Recovery coaching, monitoring via
telephone and internet;
 Substance Abuse Assistance: Outreach, peer-to-peer
services, relapse prevention, and substance abuse
education;
 Education and Job Skills: Linkages to life skills,
employment services, job training, and education
services;
 Family Support: Linkages to childcare, parent education,
child development support services, family/marriage
education;
 Support Groups: Linkages to self-help and support,
spiritual and faith-based support;
 Ancillary Services: Linkages to housing assistance,
transportation, case management, individual services
coordination.
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
Regulatory
Authority
Y
NI
IA
NA
Title 22
§51341.1(h)(6)(B)
□
□
□
□
Title 9 §10415
□
□
□
□
DMC Organized
Delivery system Waiver
□
□
□
□
Compliance Findings/Notes
19
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
12. Client Fair Hearing Rights
- Providers comply with client notification of fair hearing requirements
that involve the denial, involuntary discharge, or reduction in DMC
substance use disorder services as it relates to their eligibility for
benefits by providing written notification at least 10 calendar days
prior to the effective date of the intended action to terminate or reduce
services that includes:
 Statement of action to be taken;
 Reason for intended action; Citation of the specific regulations
supporting intended action;
 Explanation of client’s right to fair hearing for purpose of
appealing the intended action;
 Explanation that client may request a fair hearing by submitting a
written request to the Department of Social Services; and
 Explanation that provider will continue treatment services pending
a fair hearing decision?
Regulatory
Authority
Y
NI
IA
NA
Title 22
□
□
□
□
§51341.1(h)(7)
Compliance Findings/Notes
- Copy of written notification in client individual patient record?
1
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
20
Regulatory Authority Abbreviations: AOD Cert. Stds. = Alcohol and/or Other Drug Program Certification Standards (March 2004); DMC = Drug Medi-Cal Certification Standards for
Substance Abuse Clinics (July 1, 2004; DTS = Standards for Drug Treatment Programs (September 1982); Title 9 = California Code of Regulations, Title 9 - Narcotic Treatment
Programs; Title 22 = California Code of Regulations Title 22 - Drug Medi-Cal (as amended by Emergency Regulations)
Compliance Ratings Key: Y = Yes; N I= Needs Improvement; IA = Immediate Action; NA = Not Applicable
2
3
Number of Charts Reviewed: _______
4
Findings
5
Number of Yes: _______
6
Number of Needs Improvement: ________
7
Number of Immediate Action: ________
8
Program meets contractual requirements and goals? _______
9
Plan of Correction? ______ Yes
______ No
0
1
PROVIDER EVALUATION SUMMARY:
2
__________________________________________________________________________________________________________________
3
__________________________________________________________________________________________________________________
4
__________________________________________________________________________________________________________________
5
__________________________________________________________________________________________________________________
6
__________________________________________________________________________________________________________________
7
8
9
________________________________
____________________________________
__________________________________
0
Compliance Officer Printed Name
Signature
Date
2
________________________________
____________________________________
__________________________________
3
Provider Representative Printed Name
Signature
Date
1
Prepared by Golden Bear Associates for SFHN-BHS * June 2015
21