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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJune 2015

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Statutory Authority: 16 Delaware Code, §§2205(10), 2207(a) and 2208(b)
(16 Del.C. §§2205(10), 2207(a) & 2208(b))
In accordance and compliance with the procedures set forth at 29 Del.C. §1131, et seq. and 29 Del.C. §10101, et seq., the Delaware Department Health and Social Services (DHSS) / Division of Substance Abuse and Mental Health (DSAMH) is proposing to repeal the current Substance Use Treatment Program Licensure Standards, located at 16 DE Admin. Code 6001, and replace them in their entirety with the following proposed regulation. Copies of the proposed regulations are available in the June Register of Regulations or by contacting DSAMH as provided below.
16 Del.C. §2205(10); 16 Del.C. §2207(a); 16 Del.C. §2208(b)
The Department is authorized by 16 Del.C., Ch. 22 to license and regulate substance use disorder and co-occurring treatment facilities. These regulations shall apply to any facility as defined in 16 Del.C., Ch. 22, and Ch. 51 and address the minimum acceptable standards and programmatic conditions for consumers/clients receiving services in substance use disorder and co-occurring disorder treatment facilities. No organization or entity shall manage or operate a substance abuse treatment facility within the State of Delaware unless it has been so licensed by the Department.
Adjunct and alternative therapymeans a specific modality of therapy based on a specific valid body of knowledge, provision of which requires specific credentials. Examples include, but are not limited to, Psychodrama; Art Therapy; Music Therapy; Acupuncture; Massage Therapy; EMDR; etc.
Administratormeans an individual who is authorized by the governing body to provide overall management of the agency.
Admission means the point in a client’s relationship with a program when the intake process has been completed and the program begins to provide additional services.
Advisory Council means a group of individuals approved by the governing body, to provide community input and recommendations to the governing body.
Agency means any partnership, corporation, association, or legal entity except for an individual practitioner, that provides, is seeking to provide, or holds itself out as providing alcohol and/or other drug treatment or rehabilitation services. An agency may operate more than one program.
Applicantmeans any agency that has submitted a written application for a license to operate an alcohol and/or other drug abuse treatment or rehabilitation program in Delaware.
Client means an individual who receives, or has received services from an agency.
Client Recordmeans the official legal written file for each client containing all the information required by these regulations, and maintained to demonstrate compliance with these regulations.
"Clinical director" means an individual who, by virtue of education, training, and experience, satisfies the requirements of §6.1.2.1 and/or §16.2.3 of these regulations and is authorized by the Administrator to provide clinical oversight of the treatment program. The Clinical director may also serve as Clinical supervisor when directed to do so by the agency's governing body.
"Clinical supervisor" means an individual who, by virtue of education, training, and experience, satisfies the requirements of §6.1.3.1 of these regulations; and is authorized by the Administrator and/ or the governing body to provide clinical supervision for all clinical staff.
Continuing care means those services recommended to the client upon discharge from a program that support and increase the gains made during the client’s treatment at that program.
Counseling means the process in which a Counselor I or Counselor II works with a client, family, significant other, or a group of clients, families or significant others, to assist them to understand issues, consider alternatives, and change behaviors.
Individual counseling is the face-to-face, video or telephone interaction between a Counselor I or Counselor II and an individual client for a specific therapeutic purpose.
Family counseling is the face-to-face interaction between a Counselor I or Counselor II and the family member(s)/significant other(s) of a client for a specific therapeutic purpose.
Group counseling is the face-to-face interaction between a Counselor I or Counselor II and two or more clients or clients’ families/significant others for a specific therapeutic purpose.
Counselor I means an individual who, by virtue of education, training, and experience meets the requirements of §6.1.4.1 of these regulations and functions under the supervision of a Clinical supervisor.
Counselor IImeans an individual who, by virtue of education, training, and experience, meets the requirements of §6.1.5.1 of these standards and functions under the supervision of a Clinical supervisor.
Cultural Competencemeans acceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to service models in order to better meet the needs of minority populations. Culturally competent agencies work to hire unbiased employees, seek advice and consultation from the minority community, and actively decide what they are and are not capable of providing to minority clients. (March, 1989, Towards a Culturally Competent System of Care, Volume 1, National Technical Assistance Center for Children’s Mental Health, Georgetown University Child Development Center, p. 17.)
Day” unless otherwise specified, one (1) day is a calendar day.
Deemed statusmeans a licensure standing approved by DSAMH and bestowed upon programs that have been accredited by an accreditation body approved by DSAMH. Programs that have been granted Deemed Status will be inspected in accordance with §4.3.2 of these standards.
Designee means the person who is delegated tasks, duties, and responsibilities when such designation is permitted by these regulations.
Discharge means the point at which a client’s active involvement with an agency is terminated.
Division/DSAMH means the Delaware Division of Substance Abuse and Mental Health within the Delaware Department of Health and Social Services.
Division Director means the Director of the Delaware Division of Substance Abuse and Mental Health within the Delaware Department of Health and Social Services, or his/her designee.
Documentation means a written record acceptable as evidence to substantiate compliance with these regulations.
DSMmeans the Diagnostic and Statistical Manual of Mental Disorders, most recent edition, as published by the American Psychiatric Association.
Facilitymeans the physical area, grounds, building(s) or portions thereof, under direct program administrative control.
Follow-up means the process for determining the status of an individual who has been referred to an outside resource for services or who has been discharged from services OR the process for determining an agency’s compliance with these standards after an agency audit has been completed.
Governing Body means the individual or individuals responsible for the overall management of an agency, responsible for ensuring compliance with 5.0 of these regulations.
"Initial Recovery Plan" means the first recovery plan developed on the first day of treatment. The initial recovery plan is a working document created with input from the client and program staff.
Intake means the gathering of personally identifying and clinical data required to determine whether a client should be admitted to a program.
Intern means a student who performs counseling functions under the supervision of a Clinical supervisor.
Licensemeans the document issued by the Division that authorizes a program to provide alcohol and/or other drug treatment or rehabilitation.
Licensed Nurse means a Registered Nurse or a Licensed Practical Nurse.
Licensed Practical Nurse means a person licensed by the State of Delaware as a Practical Nurse or a person licensed by a state that participates in the National Licensure Compact (NLC).
Licensure means the process by which the Division determines whether or not a program is in compliance with these regulations.
Medical historymeans history of and any treatment of allergies, head injuries, nervous disease/disorders, seizure disorder, or delirium tremens, surgery, major accidents, fractures, venereal diseases, cardiovascular, respiratory, endocrine, gastrointestinal diseases or disorders, and gynecological-obstetrical history, including current involvement in prenatal care and current medical treatment by a Primary Care Physician or other medical doctor.
"Needs Assessment" means a systematic evaluation of current system and programmatic operations and projected needs. This evaluation is performed as part of the Quality Assurance Plan and focuses on the changing needs of the community and population served.
Nurse Practitionermeans a person licensed by the State of Delaware as a Nurse Practitioner or a person licensed by a state that participates in the National Licensure Compact (NLC).
"Periodic Recovery Plan Review/Revision" is a process whereby the clinical supervisor, and counselor, review prior recovery plans and establish new goals based on the client's progress and/or changing needs through out treatment.
Physicianmeans a person licensed to practice medicine in the State of Delaware.
Physician Assistantmeans a person licensed by the State of Delaware as a Physician Assistant.
Policy means a statement of the principles that guide and govern the activities, procedures and operations of a program.
Procedure means a series of activities designed to implement the policies of a program.
Program means the location or facility where an agency provides or offers to provide any of the various modalities of service when such services are provided or offered on a regularly scheduled basis. Clinical participation records of clients are EITHER stored on-site OR readily available to staff in electronic format using computer hardware that is installed or regularly available on-site.
Protocols means a written rule developed by an agency to govern specific procedures or certain activities.
Provisional License means the document issue by the Division that authorizes a program to provide alcohol and/or other drug treatment or rehabilitation for up to one hundred and eighty (180) days when the applicant is not in compliance with these regulations or is applying for licensure for the first time.
Public place means an area accessible to clients, employees or visitors; the main entry or hallway; the reception area or foyer; or the dining or multipurpose room.
Qualified Medical Personnelmeans a physician, physician’s assistant, or nurse practitioner, licensed by the State of Delaware.
"Qualified Psychiatric Practitioner" means a physician or nurse practitioner, licensed by the State of Delaware with specific clinical experience in the treatment of substance use disorders as well as mental health disorders. Qualified Psychiatric Practitioners must have specific training in the use of buphrenorphine and Opioid antagonist medications as well as the use of psychotropic medications used with individuals who have a mental health diagnosis.
Quality Assurance means the process of objectively and systematically monitoring and evaluating the quality and appropriateness of client care to identify and resolve identified issues.
Readmission means the point in a client’s relationship with an agency when a client has been discharged, subsequently reapplied for admission, intake has been completed, and the agency begins to provide services again.
Registered Nursemeans a person licensed by the State of Delaware as a registered nurse or a person licensed by a state that participates in the National Licensure Compact (NLC).
Shallmeans a mandatory procedure, the only acceptable method under these regulations.
Signature/Signed means, at a minimum, the writers’ first initial, last name, title or credentials and date or an authentic digital signature OR the client or legal guardian’s first and last name and/or date when required.
Significant othermeans an individual, whether or not related by blood or marriage, on which another individual relies for support.
Staff means full-time and part-time employees, consultants and volunteers, students/interns.
Treatment means the process a client undergoes to understand his or her alcohol or drug use and/or mental health diagnosis and choices made to change his or her behavior.
Volunteer means a person who, without direct financial compensation, provides services to a program.
Waiver means the exemption from compliance with a requirement of these regulations.
4.3.2 Applicants applying for Deemed Status shall meet all standards as outlined in §17.0, §18.0 and §19.0 of these standards (as applicable).
4.3.3 Applicants shall supply all information requested on the application. The completed application shall be accompanied by a $15.00 fee in accordance with 16 Del.C. §2205. The Division shall not consider any application until it is properly completed and payment has been received.
4.8.1.1 Issue or renew a full license for a period of up to two years when the Division determines a program is in substantial compliance with Chapter 22 of Title 16 Del.C., and these regulations, and/or has been granted Deemed Status or
4.8.1.4 Issue a provisional license for up to one hundred and eighty (180) days when the program is not in compliance with Chapter 22 of Title 16 Del.C., or regulations set forth by the accreditation body upon which Deemed Status has been granted (when applicable) and the applicant’s failure to meet the requirements of Chapter 22 of Title 16 Delaware Code and these regulations does not jeopardize the health, safety and well-being of clients. The Division may issue one renewal of a provisional license for a period not to exceed ninety (90) days. (The Division’s decision to issue a provisional license instead of a full license is final and not subject to administrative appeal;) or
4.12.1.5 When an applicant or program fails to implement the corrective action plan it submitted pursuant to §4.7, unless the Division approves an extension or modification of the corrective action plan;
4.12.1.6 When a program has violated any part of Title 16 Del.C., Chapter 22 or these regulations;
4.13.1 In accordance with 16 Del.C. 2208, when the Division determines that an applicant or licensee fails to meet minimum compliance with the requirements of these regulations for the types of services for which application was made or for which the program was licensed or has committed an act or engaged in conduct or practices justifying denial, suspension or revocation of licensure:
4.14.5 Hearings under this subsection shall be conducted in accordance with 29 Del.C. Chps. 100 and 101 and 4.13 of these regulations.
4.15.1 An application for a waiver from a requirement of these regulations shall be made in writing to the Division's Director of Quality Assurance; it shall specify the regulation from which waiver is sought, demonstrate that each requested waiver is justified by substantial hardship, and describe the alternative practice(s) proposed. The waiver request shall be posted in a prominent place in the facility and outline a process approved by the Division whereby clients can offer comments and feedback specific to the waiver request. The Division's Director of Quality Assurance Unit shall make a recommendation of action on the application to the Division Director or designee. The Division Director or designee will review the request and recommendations and make final waiver request decisions.
4.15.3 A waiver granted under these regulations shall be in effect for the term of the applicant's license. If a waiver is required for an additional period of time, it shall be requested as part of the licensure renewal process in accordance with §4.15.
5.1.4.4.1.16 Policies and procedures for making mandated reports of suspected child abuse or neglect in compliance with 16 Del.C. §§902 through 904, 3910, 1132, 2224, 5194 and 42 CFR § 2.12(c)(6) (including non-retaliation policies when personnel report abuse and neglect.);
5.1.7.1.1.2 Program policies and procedures regarding the reporting of cases of suspected child abuse or neglect in compliance with 16 Del.C. §§902 through 904, 910, 1132, 2224, 5194 and 42 CFR § 2.12(c)(6), including non-retaliation policies when personnel report abuse and neglect;
5.1.7.4.2 Three (3) hours specific to training and education in providing culturally competence services every two years; and
5.1.7.5.1 Every program utilizing any modalities of adjunct or alternative therapy shall ensure:
6.1.2.1 Each individual, hired or promoted, to the position of Clinical Director on or after the date these regulations become effective shall have, at a minimum:
6.1.4.1.3 Five (5) years of clinical experience working in the field of substance abuse treatment.
6.1.5.1.1 A person who does not meet the educational and experiential qualifications for the position of Counselor as set forth in §6.1.4 may be employed as an Counselor II if the requirements of at least one of the following paragraphs are met:
7.1.2.1.5 To refuse service, except as provided in 16 Del.C. §§2211, 2212, 2213 and 2215. If consequences, such as termination from other services, may result from such refusal, that fact shall be:
10.1.7.2 Every fifth (5th) day thereafter.
10.1.8 For those clients not medically restricted individual counseling that shall include at least one (1) (fifteen) 15 minute counseling contact per day with a Counselor I or Counselor II.
12.1.1.2 A physical examination in accordance with §8.1.2.1.2.1.7 within seventy-two (72) hours of admission, unless the client presents a copy of a physical examination completed by qualified medical personnel within ninety (90) days prior to admission.
12.2.4 Counselor I’s and Counselor II’s shall meet face-to-face with clinical supervisors a minimum of one (1) hour per Counselor per week for clinical supervision.
12.4.2.7 The right to practice their personal religion or attend religious services, within the program’s policies and written policies for attendance at outside religious services.
14.2.4.2 In addition to the consent of the client, Individuals under 18 years old, unless otherwise permitted by 16 Del.C. §2210 to consent to treatment, have had a parent or legal guardian complete and sign the agency's consent to OTP Treatment.
14.8.2 Documentation of the rationale for revoking or suspending take-home privileges will be entered into the client's record by the medical director.
15.1.1.4.1 Every ninety (90) days after the effective date of the first treatment plan.
17.3.2 Programs must report all sentinel events to DSAMH within twenty-four (24) hours accompanied by the root cause analysis, action plan and action plan follow up activity reports prepared according to JCAHO guidelines.
17.3.3 Programs must submit to DSAMH any corrective action to address sentinel events at the same time they are submitted to JCAHO.
17.5.2 Section §9.0: Programs with Deemed Status are exempt from all standards in section §9.0. with the exception of §9.1.5. “smoke free facility”.
2.1 The Department is authorized by 16 Del.C. Chs. 1 and 22 to license and regulate substance use treatment programs and facilities. These regulations shall apply to any program or facility as defined in 16 Del.C. Ch. 22 and address the minimum acceptable standards and programmatic conditions for clients receiving services in substance use treatment or rehabilitation service or program in Delaware. No organization or entity shall manage or operate such a treatment program or facility within the state of Delaware unless it has been so licensed by the Department.
42 CFR Part 2” means part 2 of Title 42 of the U.S. Code of Federal Regulations referring to the confidentiality of substance abuse client records, as the same may be amended.
Admission” means the point in a client’s relationship with a program when the intake process has been completed and the program begins to provide services.
Agency” means any partnership, corporation, association, or other legal entity, except for an individual practitioner and group practices, that provides, is seeking to provide, or holds itself out as providing substance use treatment and/or rehabilitation services or program(s). An agency may operate more than one program or service.
Applicant” means any agency that has submitted a written application for a license to operate a substance use, non-substance-related addictive disorder, mental health, or co-occurring disorder treatment or rehabilitation service or program in Delaware.
ASAM” means the American Society of Addiction Medicine.
ASAM Criteria” means the latest version of the American Society of Addiction Medicine (ASAM) Criteria.
Behavioral Health” refers in these regulations to any substance use, addictive, and/or mental health disorder.
Behavioral Health Technician” means an unlicensed individual, who is at least 18 years of age with a high school diploma or equivalent who has been trained in the relevant ASAM Level of Care criteria.
Behavioral Management” means any intervention or treatment that utilizes positive reinforcement and/or restrictions to help a client receiving services to develop and/or strengthen recovery-oriented behaviors and to address and correct treatment targeted behaviors
Client Record” means the comprehensive file for each agency client containing all the information required by Section 8.0 of these regulations and maintained by the agency providing services to the client pursuant to these regulations. Records must be available on-site or electronically accessible at all times.
"Clinical Director" means an individual who, by virtue of education, training, and experience, satisfies the requirements of these regulations and is authorized by the agency administrator to provide clinical oversight of the treatment program. The clinical director may also serve as clinical supervisor when directed to do so by the agency's governing body.
"Clinical Supervisor" means an individual who, by virtue of education, training, and experience, satisfies the requirements of these regulations; and is authorized by the agency to provide clinical supervision for all clinical staff.
Compliance” means a program adheres to these regulations in accordance with the relevant licensing standards.
Continuing Care” means those services recommended by the program to the client upon discharge from a program that support and increase the gains made during the client’s treatment.
Co-occurring Disorder” means substance use, addictive disorders, and mental health disorders that co-exist; a term interchangeable with “dual diagnosis”.
Counseling” means the process in which a Counselor works with a client, family, significant other, or a group of clients, families or significant others, to assist them to understand issues, consider alternatives, and change behaviors.
Individual counseling is the face-to-face, video or telephone interaction between a Counselor and an individual client for a specific therapeutic purpose.
Family counseling is the face-to-face interaction between a Counselor and the family member(s)/significant other(s) of a client for a specific therapeutic purpose.
Group counseling is the face-to-face interaction between a Counselor and two or more clients or clients’ families/significant others for a specific therapeutic purpose.
Day” means, unless otherwise specified, one (1) calendar day.
Deemed Status” means a licensure status given to a program which is accredited by the Joint Commission (JC) Commission on Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation (COA) and which exempts the program from Division monitoring pursuant to these regulations except for complaint based investigations and corresponding actions by the Division.
Department of Health and Social Services” means the State of Delaware Department of Health and Social Services, including its Division of Substance Abuse and Mental Health (“DSAMH” or “Division”).
Discharge” means the point at which a client’s active involvement with a program is terminated.
Division Director” means the Director of DSAMH or the Director’s designee.
Evidence-based programs and practices (EBPs)” means programs or practices that are validated by some form of documented scientific evidence (in contrast to approaches that are based on tradition, convention, belief, or anecdotal evidence). A listing of applicable EBPs can be found at: http://www.nrepp.samhsa.gov/.
Facility” means the physical area, grounds, building or portions thereof, where the program is operated, including administrative offices.
Follow-up” means the process for determining the status of an individual who has been referred to an outside resource for assistance or services, including an individual who has been discharged from services, OR the process for determining an agency’s compliance with these standards after an agency audit has been completed.
HIPAA” means the Health Insurance Portability and Accountability Act of 1996, 45 CFR Parts 160 and 164.
History and Physical” means the initial clinical evaluation and examination of a client to include a medical history, a nursing assessment, a physical examination, and if needed, laboratory tests, tests for contagious diseases, and other related diagnostic tests.
Inactive Status” means a program is not eligible to see clients; however is provided with a provisional license.
"Initial Recovery Plan" means a preliminary recovery plan developed upon admission to the program. The initial recovery plan is a working document created with input from the client and multi-disciplinary program staff.
Intake” means the gathering of personally identifying and clinical data required to determine whether a client should be admitted to a program.
Licensed Behavioral Health Practitioner (LBHP)” means a professional who is licensed in the State of Delaware to diagnose and treat mental illness or substance abuse acting within the scope of all applicable State laws and their professional license. Qualifying LBHP recognized for the purpose of these regulations are as follows:
Medical Director” means a medical doctor authorized by an agency’s governing body and policies to be responsible for overseeing medical services provided in a licensed program.
Medically Supervised Withdrawal” means dispensing of medically appropriate medications in gradually decreasing doses to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of opioid drugs. The purpose of medically supervised withdrawal is to bring a patient maintained on maintenance medication to a medication-free state within a target period.
Medication Assisted Treatment (MAT)” means the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.
Non-Substance-Related Addictive Disorder” means behavioral addictions, such as gambling, that are similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment and result in preoccupation that can lead to clinically significant impairment or distress.
Opioid Treatment Program (OTP)” means a program that is federally certified by Substance Abuse and Mental Health Services Administration (SAMHSA) under 42 CFR Part 8.11 to provide specific medication-assisted treatment to opioid-dependent persons, as regulated by DSAMH under the purview of the Delaware State Opioid Treatment Authority (SOTA).
Program” means the substance use treatment modalities of service provided by an agency.
Program Director” means an employee responsible to the agency for the direct operation of a program.
Program Physician” means a physician either employed by, or under written contract with, an agency for the purpose of providing direct services to clients served by the agency.
Progress Notes" means written or electronic record of services and supports provided to an individual documenting the individual's participation in, and response to, treatment, progress in recovery, and progress toward intended outcomes.
Provisional license” means the document issued by the Division that authorizes a program to provide substance use, non-substance-related addictive disorder, and/or co-occurring disorder treatment or rehabilitation for up to one hundred and eighty (180) days when first time applicant for licensure has had its application accepted by the Division pending a full licensure inspection or a current licensee has been determined by the Division to be not in compliance with these regulations pending additional action.
Psychiatrist” means an individual who possesses a valid State of Delaware license to practice medicine and has completed an accredited residency training program in psychiatry.
Qualified Health Professional (QHP)” means a practitioner who is currently registered with their respective Delaware professional board and provides clinical and administrative oversight and supervision of non-credentialed staff in a manner consistent with their scope of practice specifically for behavioral health services. QHPs include LCSWs, LPCMHs, LMFTs, LCDPs, and Psychologists.
Qualified Medical Professional (QMP)” means Advanced Practice Registered Nurse (APRN), Physicians Assistants (PA), Nurse Practitioner (NP), Doctor of Medicine (MD), and Doctor of Osteopathic Medicine (DO).
Quality Assurance” means the process of objectively and systematically monitoring, and evaluating the quality and effectiveness of client care outcomes and to avoid, identify and/or resolve client care quality issues
Recovery” means a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
"Recovery plan update” is a process completed according to the treatment modality for which the program is licensed. In this process the clinical supervisor and counselor review prior recovery plans, and, in collaboration with the client, family/natural supports, and other relevant providers, establish current goals and objectives based on the client’s progress and/or changing needs.
Safety Plan” means a practical guide that is personalized to the client that identifies specific triggers/stressors, warning signs/symptoms, coping skills, relapse prevention, supports, etc.
Secretary” means the Cabinet Secretary of the Delaware Department of Health and Human Services.
Signature/signed” means, at a minimum, the writers’ first name, last name, title or credentials and date or an authentic digital signature or the client or legal guardian’s first and last name and date when required.
Substance” means alcohol, nicotine, other drugs and medications or compounds or materials having chemical properties that after entering a human body, affects the person in a manner that alters mood and/or perception.
Substance Use Disorder” - the essential feature of a substance use disorder is a cluster of cognitive, behavioral and physiologic symptoms indicating that the individual continues using the substance despite significant substance-related problems.
Treatment” means the process a client undergoes to understand his or her alcohol or drug use and/or mental health diagnosis and choices made to change his or her behavior and improve health and functioning.
Unlicensed counselors and assessors” includes, Bachelor and Master level clinicians, certified alcohol and drug counselor (CADC), internationally certified alcohol and drug counselor (ICADC), certified co-occurring disorders professional (CCDP), internationally certified co-occurring disorders professional (ICCDP), internationally certified co-occurring disorders professional diplomat (ICCDPD),
Withdrawal management” means a set of interventions aimed at managing acute intoxication and withdrawal. It is often the first step taken by clients with a substance use disorder and typically needs to be followed by referral to a continuum of health and social services that is inclusive of assessment services, active treatment and continuing care.
4.6.6 When a program has violated any part of 16 Del.C., Chapter 22 or these regulations;
4.7.1 In accordance with 16 Del.C. §2208, when the Division determines that an applicant or licensee fails to meet minimum compliance with the requirements of these regulations for the types of services for which application was made or for which the program was licensed or has committed an act or engaged in conduct or practices justifying denial, suspension or revocation of licensure the Division shall notify the applicant or licensee by certified mail, return receipt requested, of its intent to deny, suspend or revoke the license. The “Notice of Intended Action” shall include the particular reason(s) for the proposed action and provision for a fair hearing.
4.8.7 Hearings under this subsection shall be conducted in accordance with 29 Del.C. Chapters 100 and 101 and subsection 4.7 of these regulations.
6.1 Qualifications for the Position of Administrator
6.1.1 Each agency shall have an administrator responsible for the overall management of the program and staff.
6.1.2 Each administrator hired or promoted on or after the date these regulations become effective shall have at a minimum a Bachelor’s Degree from an accredited college or university with at least 5 years of documented experience in human services including:
6.1.2.1 At least two (2) years of experience in mental health and/or substance use disorders treatment; and
6.1.2.2 A least two (2) years of relevant management experience.
6.2 Qualifications for the Position of Clinical Director
6.2.1 Each individual, hired or promoted, to the position of Clinical Director on or after the date these regulations become effective shall have, at a minimum:
6.2.1.1 A Master's Degree in counseling or a related discipline; and
6.2.1.2 At least five (5) years of documented clinical experience in human services, at least three (3) years of which shall be in mental health and/or substance use disorder services; or
6.3 Qualifications for the Position of Clinical Supervisor
6.3.1 Each individual providing clinical supervision on or after the date these regulations become effective shall meet one of the following:
6.3.1.1 At minimum, a Bachelor’s Degree from an accredited college or university with a major in chemical dependency, psychology, social work, counseling, nursing or a related field of study and full certification as a certified alcohol and drug counselor (CADC), internationally certified alcohol and drug counselor (ICADC), certified co-occurring disorders professional (CCDP), internationally certified co-occurring disorders professional (ICCDP), internationally certified co-occurring disorders professional diplomate (ICCDPD), or licensed chemical dependency professional (LCDP); or
6.3.1.2 At minimum, a Bachelor’s Degree from an accredited college or university with a major in chemical dependency, psychology, social work, counseling, nursing or a related field of study and five (5) years of documented clinical experience in the substance use, mental health, or co-occurring treatment field and; or
7.1.1 No agency shall deny any person equal access to its programs or facilities on the basis of race, color, religion, ancestry, sexual orientation, gender expression, national origin, or disability.
7.1.2 No agency shall deny any person equal access to its programs or facilities on the basis of age, sex, or gender except those programs that specialize in the treatment of a special population, such as, adolescents aging into adults, pregnant women, and mothers with children.
7.1.3 All agencies shall comply with 11 Del.C. §1121 (Rights of Patients in Nursing Facilities and Similar Facilities); 16 Del.C. §2220 (Substance Abuse Treatment Act Patient’s Rights), and 16 Del.C. §5182 (Community Mental Health Patients' Rights), as applicable.
7.1.4 All agencies shall ensure that they comply with the federal Americans with Disabilities Act, 28 U.S.C. §§12101 et seq. and 28 Code of Federal Regulations, Part 36 (July 1991) and 16 Del.C. §2220.
7.1.5 All agencies shall ensure they comply 16 Del.C. §§2211, 2212, 2213 and 2215.
8.1.1.4 Comply fully with all applicable federal and state privacy statutes and regulations, including HIPAA and 42 CFR Part 2.
8.1.1.5 Update each relevant record within twenty-four (24) hours of delivery of a service unless otherwise specified in these regulations.
8.1.2 Any agency that discontinues operations, or is merged with, or acquired by another agency is responsible for ensuring compliance with the requirements of 42 CFR §2.19, and HIPAA. The agency shall document the following in writing to the Division:
8.1.2.1 How it will adhere to 42 CFR §2.19 and HIPAA at the time it notifies the Division of the program closure in accordance with these regulations; and
8.1.2.2 How it will adhere to Section 8.0 of these regulations.
8.1.5 Programs shall provide a list of referral sources for the client’s various needs when the agency is unable to meet the client’s needs internally. The agency shall be responsible for assisting the client in enrolling in services at other agencies, and document referral efforts and outcomes in the client record.
8.1.6 Programs shall provide a minimum of twelve (12) months of records up until and including the expiration date of the current license for the purposes of licensure audit. Programs shall develop a policy that clearly outlines timelines for record retention and storage for all records beyond the required audit period.
8.2 Content of Client Records
8.2.1 A record shall be established for each client upon admission and shall include:
8.2.1.1 A Consent to Treatment form signed and dated by the client and, if the client is a minor, the client’s parent or guardian, except as provided in 16 Del.C. §2210(b).
8.2.1.2.8.5 The name and telephone number of the person to contact in an emergency to include relationship;
8.2.1.3 Consent to Release Information forms
8.2.1.4.1 Acknowledging receipt of the notice of client rights;
8.2.1.4.2 Acknowledging his/her understanding of the agency's agreement with the confidentiality requirements of these regulations;
8.2.1.4.3 Acknowledging receipt of the program's procedures when an emergency occurs outside of the program's hours of operation.
8.2.1.5 Copies of any laboratory reports and drug tests ordered by the program;
8.2.1.6 Informed consent regarding prescribed pharmacotherapy obtained from the client prior to delivery of the medication prescription;
8.2.1.7 Results of the client's diagnostic assessment, including the client's:
8.2.1.7.7.4 Frequency of substances used;
8.2.1.7.8 Past supports and resources that were effective in previous recovery attempts;
8.2.1.7.10 Reason(s) for seeking treatment;
8.2.1.7.12 History of other addictive disorders;
8.2.1.7.13.2 Use of alcohol and other drugs by family members and significant others.
8.2.1.7.14 A diagnostic assessment summary of the client's status that addresses the client's:
8.2.1.7.17 The rationale for placement recommendations:
8.2.1.7.17.2 Reviewed, as indicated by the signature (including date and time) of the clinical supervisor; and
8.2.1.7.17.3 Is completed prior to the development of the initial Recovery Plan.
8.2.1.8 Copies of all correspondence related to the client.
8.2.1.9 An individualized Recovery Plan developed in partnership with the client and any identified and relevant natural supports shall be completed no later than the time required in these regulations for the modality for which the program is licensed.
8.2.1.9.1.3.1 To be treated.
8.2.1.9.1.5.1 Which services and/or activities/interventions will be used to achieve each Recovery Plan objective;
8.2.1.9.1.5.2 The frequency of each service and/or activity/intervention to meet the goals/objectives;
8.2.1.9.1.6.2 The counselor who developed the Recovery Plan; and
8.2.1.10.1 Recovery Plans shall be updated with the client present and any identified and relevant natural supports when clinically appropriate, and his/ her counselor, no less often than the intervals specified for the modality for which the program is licensed, or when there is a significant change in functioning.
8.2.1.10.2 The Recovery Plan Update shall address the issues remaining to be treated (including goals/objectives to be deferred/referred) as derived from the Recovery Plan.
8.2.1.11.1 Each contact made with or on behalf of the client in accordance with the goals/objectives and interventions/activities prescribed on the recovery plan shall be documented in the client file; and
8.2.1.11.1.1.2 The date and time of the service(s) provided;
8.2.1.11.1.1.3 The length of the service(s) provided;
8.2.1.11.1.1.4.1 a description of the service and activity;
8.2.1.11.1.1.4.3 a description of the client’s response to the session
8.2.1.11.1.1.5.1 the counselor’s assessment of the client's response or lack of response to the service and/or activity and
8.2.1.11.1.1.5.2 the client's progress or lack of progress toward achieving the objectives prescribed in the recovery plan;
8.2.1.11.1.1.6 Plan for future sessions
8.2.1.11.1.1.6.1 anticipated implementation, by the counselor, of services and/or activities as prescribed in the recovery plan.)
8.2.1.12.1 In anticipation of successful completion or planned interruption of a client's treatment, the treatment staff and client shall jointly develop a discharge plan and document the process in the progress notes.
8.2.1.13.1 For every client that is discharged, the program shall complete a discharge summary within seventy-two (72) hours of a planned discharge and within ninety-six (96) hours of an unplanned discharge.
8.2.1.13.2.6 A summary of the client’s progress or lack of progress toward meeting recovery plan goals/objectives;
8.2.1.13.2.7 A summary of the client's participation in treatment;
8.2.1.13.2.10 Recommendations and referrals regarding the need for additional services which may include: relapse prevention, social supports, medical, vocational, etc.
8.2.1.13.2.11 When the discharge is planned, the discharge summary shall be signed and dated by:
9.1.1 Privacy for communications between clients and staff members;
9.1.2 Rest rooms for clients, visitors and staff and the separation of bathroom facilities serving male and female clients.
9.2 Agencies shall maintain up-to-date documentation verifying that they have a certificate of occupancy and meet applicable federal, state and local building, zoning, fire, and safety and accessibility requirements.
9.3 Agencies shall maintain facilities in neat and clean condition, and eliminate any hazardous conditions that endanger the health or safety of clients, visitors or staff.
9.5 Agencies shall post hours of operation in a public place within the facility.
9.6.1 Agencies shall display up to date certificates or approval/inspection by Fire Department authorities whenever this is required/available in the specific community where the program is located.
9.7.1 Each agency shall establish a plan of action in the event of emergencies or disasters, based on the program’s capability and limitations. The plan shall include provisions:
9.7.1.1 For responding to severe weather, loss of power or water or other natural disaster;
9.7.1.4 For responding to accidents that result in injury or death;
9.7.1.6 Governing how the program will effectively activate community resources to prevent or minimize the consequences of a disaster;
9.7.1.7 Concerning staff preparedness and the designation of roles and functions;
9.7.1.8 Concerning criteria for the cessation of nonessential services and client transfer determinations; and
9.7.1.9 Governing how it will protect the safety of clients and staff and the security of its records.
9.7.2 All treatment programs shall develop procedures for handling a client who is exhibiting behavior that is threatening to the life or safety of the client or others.
9.7.3 All treatment programs shall have a staff member on site at all times trained in:
9.7.3.2 The standard Red Cross first aid class and CPR certification, or its equivalent.