Drug and Alcohol Process

Incoming referrals: Referrals will be accepted by phone, letter or mail, an attempt will be made to contact the individual within 3-5 days from receiving the referral. If there is availability the client will be provided with an admission date as soon as possible. Otherwise, the individual will be placed on a waiting list and/or will be referred to other agencies. Individuals will be prioritized according to the highest level of need.

During the intake process the therapist will evaluate the client for appropriateness of level of care required to meet the individuals needs on an out patient basis. This process shall be based on the following:

· Diagnosis of Psychoactive Substance Dependence (DSM IV)

· Must meet at a minimum, ASAM Level 1a or 1b criteria.

· Moderate emotional/behavioral complications

· Supportive external environment for recovery

· Limited understanding of the recovery process

· Willing to participate in the level of care

Adults Admission Criteria: Any client 18 years of age or older will be evaluated for admissions based on the Pennsylvania Client Placement Criteria (PCPC) criteria for placement.

The CWA-A Scale will be used in order to determine if the client may be suffering current withdrawal symptoms at the time of Intake. This will also aid in the determination of whether the client might require a higher level of care not provided for at SCS.

If a determination is made for a higher level of care, counselor will discuss options for detox, in-patient treatment, halfway house, medically monitored, etc.. Although the client may qualify for a higher level of care, SCS recognizes that it is the client’s choice as to whether he/she will follow the recommendations for care. If the client refuses a higher level of care and wishes to remain in treatment as an outpatient client, the client will be given all 24 hour emergency services available and phone numbers. Also, on the intake summery report, PCPC criteria for higher level of care will be indicated with documentation of the clients refusal to attend a higher level of care. For each client, SCS will follow the procedures listed below:

1. An intake will be completed prior to the development of the Comprehensive Plan which shall include the following:
   1. The client psychosocial history consisting of:
      1. Medical history which includes the client's personal medical history, the client's current symptoms and prior illnesses, family medical history, and tuberculosis screening by the Department of Health will be offered.
      2. Drug and alcohol history, which includes the substances and quantities used, the pattern, length and progression of use, prior drug and alcohol treatment, the client's perception of the impact of use, and family drug and alcohol history.
      3. Personal history, which includes the family of origin and current relationships with family members and significant others, abuse, legal, employment, education, military, sexual and recreation histories.
      4. Mental health history, which includes a current and past assessment of suicidal and homicidal risk, a mental status assessment, and prior mental health treatment history.

2. A client psychosocial evaluation shall be completed at or before the conclusion of the intake process and shall include the following:
   1. An evaluation of how the client's psychosocial history, beliefs, and behaviors have contributed to the client's current problems.
   2. The client's attitudes, motivation, denial systems, beliefs and coping mechanisms and how they may impact treatment.
   3. Positive and negative factors identified through the psychosocial history that will effect treatment.
   4. Client strengths and weaknesses as identified by the counselor and the client.
   5. Counselor's impressions including a description of the client's appearance, behavior, and mental state during the intake process and the implication for treatment.
   6. Client needs and behaviors that are to be addressed in treatment and the recommended strategies to deal with these issues.

2. A Comprehensive Plan and Comprehensive Problem List (CP, CPL) shall be developed for each client receiving drug and alcohol outpatient treatment within four attendance days of the client's admission. The (CP, CPL) shall be based on issues identified in the psychosocial evaluation and the client's treatment needs.
3. The (CP, CLP) shall be developed by the counselor with input from the client.
4. The counselor and client shall sign and date the (CP, CPL). The clinical supervisor or lead counselor shall sign and date the (CP, CPL) attesting that the CP was reviewed and approved prior to implementation. A copy of the (CP, CPL) shall be made available to each client.

1. Individualized treatment goals and measurable objectives.
2. Services that meet the client's needs.
3. Type and frequency of services.
4. Referrals for outside services and the frequency of those services.

1. A review and update of the Comprehensive Plan every 60 days is required. Time shall be calculated by calendar days.
2. The counselor and the client shall jointly review the client's progress in achieving the goals and objectives of the CP and shall develop new goals and/or objectives as needed.
3. The counselor and client shall sign and date the Comprehensive Plan update.

1. Prior to a planned discharge, each client is to be assessed to determine if a different level of care is needed as determined by the Pennsylvania Client Placement Criteria or other Department of Health approved criteria. The SCS shall, based on this assessment, and with the client's written consent, make a referral to a licensed treatment provider for continuing drug and alcohol treatment if warranted.
2. A continuing care plan is to be developed by the counselor with each client. This plan is to be initiated at admission and completed prior to discharge.
3. The continuing care plan shall be a continuation of the treatment plan and shall include:
   1. Specific client goals.
   2. Identification of support services to be utilized by the client and a method for accessing community services.
   3. A method for the client to re-access drug and alcohol treatment services.
4. Continuing care plans are not required where/if consumers have left against center advice or refuse to participate in a continuing care plan. Documentation of this shall be maintained in the client's record.

1. A discharge summary shall be completed by the counselor within 7 days of the client's discharge.
2. A discharge summary will include:
   1. The reason(s) the client sought treatment
   2. Services provided by the center
   3. The client's progress in treatment
   4. The client's status on discharge

Notification of termination.

1. The center shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment. The notice shall include the specific reason(s) for the termination.
2. The center may immediately discharge a client who poses a threat to others and when the client's needs can no longer be safely met by the services provided by the center.
3. If client no-shows three times or any combination of 5 no-shows and cancellations.
4. The client shall have an opportunity to request reconsideration of any decision to involuntarily terminate treatment.

Spaw Counseling Services will conduct follow-up services on the following intervals of 3, 6, and 12 months. Follow-up documentation will be completed on the continuing care follow-up form.