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WAC 388-877B-0420 <br /> Substance use disorder opiate substitution treatment services—Clinical record content and <br /> documentation requirements. <br /> In addition to the general clinical record content requirements in WAC 388-877-0640, an agency <br /> providing substance use disorder opiate substitution treatment services must maintain an individual's <br /> clinical record. <br /> (1)The clinical record must contain: <br /> (a) Documentation the individual was informed of the federal confidentiality requirements and <br /> received a copy of the individual notice required under 42 C.F.R. Part 2. <br /> (b) Documentation that the agency made a good faith effort to review if the individual is enrolled in <br /> any other opiate substitution treatment and take appropriate action. <br /> (c) Documentation that the agency: <br /> (i) Referred the individual to self-help group(s). <br /> (ii)Addressed the individual's vocational, educational,and employment needs; and <br /> (iii) Encouraged family participation. <br /> (d) Documentation that the individual received a copy of the rules and responsibilities for treatment <br /> participants, including the potential use of interventions or sanction. <br /> (e) Documentation that the individual service plan was completed before the individual received <br /> treatment services. <br /> (f) Documentation that the individual service plan was reviewed: <br /> (i) Once every month,for the first ninety days in treatment; <br /> (ii) Once every three months,for every two years of continued enrollment in treatment;and <br /> (iii) Once every six months,after the second year of continued enrollment in treatment. <br /> (g) Documentation that individual or group counseling sessions were provided: <br /> (i) Once every week,for the first ninety days: <br /> (A) For a new individual in treatment; <br /> (B) For an individual readmitted more than ninety days since the most recent discharge from opiate <br /> substitution treatment. <br /> (ii)Once every week,for the first month,for an individual readmitted within ninety days since the <br /> most recent discharge from opiate substitution treatment; and <br /> (iii)Once every month,for an individual transferring from another opiate substitution treatment <br /> program,when the individual had received treatment for at least ninety days. <br /> 8 <br />