2018/02/07 Council Agenda Packet

{ 1 (h) Documentation of progress notes in a timely manner and before any subsequent scheduled appointments of the same type of service session or group type occur,or documentation as to why this did not occur. Progress notes must include the date,time,duration,participant names,and a brief summary of the session and the name of the staff member who provided it. (i) Documentation when an individual refuses to provide a drug testing specimen sample or refuses to initial the log containing the sample number.The refusal is considered a positive drug screen specimen. (j) Documentation of the results and the discussion held with the individual regarding any positive drug screen specimens in the counseling session immediately following the notification of positive results. (k)Justification for the change in the level of care when transferring an individual from one certified treatment service to another within the same agency,at the same location. (1)When an individual is transferring to another service provider,documentation that copies of documents pertinent to the individual's course of treatment were forwarded to the new service ( provider to include: (i)The individual's demographic information; and (ii)The diagnostic assessment statement and other assessment information to include: (A) Documentation of the HIV/AIDS intervention. ( (B)Tuberculosis(TB)screen or test result. (C)A record of the individual's detoxification and treatment history. } I (D)The reason for the individual's transfer. 1 (E)Court mandated,department of correction supervision status or the agency's recommended follow-up treatment. (F)A discharge summary and continuing care plan. (m) Documentation that a staff member(s) met with the individual at the time of discharge from the agency, unless the individual left without notice,to: (i) Determine the appropriate recommendation for care and finalize a continuing care plan. (ii)Assist the individual in making contact with necessary agencies or services. (iii) Provide and document the individual was provided a copy of the plan. (n) Documentation that the discharge summary was completed within seven working days of the individual's discharge from the agency,which includes the date of discharge and a summary of the individual's progress towards each individual service plan goal. (o) Documentation of all medical services.See WAC 388-877B-0440 and 388-877B-0450, regarding program physician responsibility and medication management. 9