Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

In the matter of the adoption of New Rules I through XXI and repeal of ARM 37.27.128, 37.27.129, 37.27.130, and 37.27.135 pertaining to emergency care, inpatient, and transitional living chemical dependency programs

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NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION AND REPEAL

TO: All Concerned Persons

1. On October 15, 2010, at 10:30 a.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed adoption and repeal of the above-stated rules.

2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on October 6, 2010, to advise us of the nature of the accommodation that you need. Please contact Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail dphhslegal@mt.gov.

3. The rules as proposed to be adopted provide as follows:

NEW RULE I PURPOSE (1) This subchapter establishes the licensing requirements for acute inpatient chemical dependency facilities, residential inpatient community-based chemical dependency facilities, and low and medium intensity residential halfway house treatment facility services.

(2) If the rules in this subchapter conflict with ARM Title 37, chapter 106, subchapter 3, the requirements of this subchapter will apply.

(3) This subchapter is applicable to treatment levels of care classified as ASAM Level:

(a) III.1 Clinically Managed Low-Intensity Residential Treatment;

(b) III.3 Clinically Managed Medium-Intensity Residential Treatment;

(d) III.7 Medically Monitored Inpatient Treatment.

(4) [NEW RULE I through XXI] are applicable to all community-based substance use disorder inpatient and residential halfway house treatment facilities.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 76-2-411, MCA

NEW RULE II DEFINITIONS In addition to the terms defined in 53-24-103, MCA, the following definitions shall apply in the interpretation and enforcement of the rules in this subchapter:

(1) "Administrator" means the person in charge, care, or control of treatment and responsible for operation of the agency providing such services.

(2) "Admission" means specific tasks necessary to admit a person to community-based substance use disorder treatment services. Tasks include but are not limited to:

(a) completion of admission forms;

(b) notification of client rights and confidentiality regulations;

(d) review of the intake policies and procedures of the service program;

(e) orientation to the service structure; and

(f) financial determination for services.

(3) "Adult" means a person 21 years of age or older for purposes of services in community-based substance use disorder inpatient and residential halfway house treatment.

(4) "American Society of Addiction Medicine Patient Placement Criteria 2R (ASAM PPC-2R) or (ASAM)" establishes the level of care for substance use disorder treatment and is required to be used by all licensed community-based substance use disorder inpatient and residential halfway house treatment facility providers. The department adopts and incorporates by reference the American Society of Addiction Medicine Patient Placement Criteria, Second Edition-Revised; Copyright 2001 by the American Society of Addiction Medicine, Inc.; ISBN 1-880425-06-8, which sets forth the level of care for substance use disorder treatment. A copy of ASAM PPC-2R may be obtained from American Society of Addiction Medicine, 4601 N. Park Avenue, Upper Arcade #101, Chevy Chase, MD 20815; phone (301) 656-3920; fax (301) 656 3815; or email@asam.org.

(5) "Biopsychosocial assessment" means an assessment of a person's medical (biological), psychological, and social history based on the six dimensions of ASAM. The six assessment dimensions include:

(a) acute intoxication and/or withdrawal potential;

(b) biomedical conditions and complications;

(d) readiness to change;

(e) relapse, continued use or continued problem potential; and

(f) recovery/living environment.

(6) "Child or adolescent" means a person under 21 years of age for purposes of services in community-based substance use disorder inpatient and residential halfway house treatment.

(7) "Client" means a person being treated for a substance use disorder who is formally admitted to services within the admission criteria set by the program.

(8) "Confidentiality" means a program requirement concerning client information, including client records. The disclosure of any information related to an individual client shall be governed by requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the requirements of Title 42 Part 2.22 (a)(1) and (2) of the Code of Federal Regulations (CFR).

(9) "Continuing care plan" means a written plan outlining anticipated therapeutic interventions to move a client along the continuum of care, which may include the level of treatment, clinical needs, and rationale for moving from one level of care to another.

(10) "Co-occurring" means an individual has at least one mental disorder and a substance use disorder.

(11) "Detoxification (detox)" means care and treatment of a person while the person recovers from the transitory effects of acute or chronic intoxication or withdrawal from alcohol or other drugs.

(12) "Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or (DSM)" establishes criteria for diagnosing an individual with a substance use or dependence disorder and is published by the American Psychiatric Association. The department adopts and incorporates by reference the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition, (ISBN 0-89042-061-0 (hardback) or ISBN 0-89042-062-9 (paperback), which sets forth criteria for diagnosing an individual with a substance use or dependence disorder. A copy of the DSM-IV may be obtained from American Psychiatric Publishing, Inc., 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209; phone (703) 907-7322 or (800) 368-5777; fax (703) 907-1091; or e-mail appi@psych.org.

(13) "Dual diagnosis capable (DDC)" means treatment programs address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content, and discharge planning are described as "dual diagnosis capable". Such programs have arrangements in place for coordination and collaboration with mental health services. They also can provide psychopharmacologic monitoring and psychological assessment and consultation, either on-site or through coordination consultation with off-site providers. Program staff is able to address the interaction between mental and substance-related disorders and their effect on the patient's readiness to change, as well as relapse and recovery environment issues, through individual and group content. Nevertheless, the primary focus of DDC programs is the treatment of substance-related disorders.

(14) "Dual diagnosis enhanced (DDE)" describes treatment programs that incorporate policies, procedures, assessments, treatment, and discharge planning processes that accommodate patients who have co-occurring mental and substance-related disorders. Mental health symptom management groups are incorporated into addiction treatment. Motivational enhancement therapies specifically designed for those with co-occurring mental and substance-related disorders are more likely available (particularly in outpatient settings) and, ideally, there is close collaboration or integration with a mental health program that provides crises back-up services and access to mental health case management and continuing care. In contrast to dual diagnosis capable services, dual diagnosis enhanced services place their primary focus on the integration of services for mental and substance-related disorders in their staffing, services, and program content.

(15) "Eligible licensed addiction counselor (ELAC)" means an individual who meets requirements set forth in 37-35-202, MCA, and ARM 24.154.407 to provide addiction counseling services under supervision of a licensed addiction counselor. References in this subchapter to licensed addiction counselor or LAC include an eligible licensed addiction counselor or ELAC providing addiction counseling services within the scope of this supervision.

(16) "First aid" means emergency treatment by someone who has received appropriate training. The provider and all staff must complete required training and hold current certification in first aid and cardiopulmonary resuscitation (CPR).

(17) "Halfway house" means a community residential facility for treatment of substance use disorders.

(18) "Licensed addiction counselor (LAC)" means an individual who meets the requirements set forth in 37-35-202, MCA, and ARM Title 24, chapter 154, rules implementing 37-35-202, MCA, to provide addiction counseling.

(19) "Licensure bureau" means the area of the department responsible for licensing chemical dependency facilities.

(20) "Medication administration" means the direct application of a medication or device by ingestion, inhalation, injection, or any other means, whether self-administered by a resident, or administered by a parent or guardian (for a minor), or an authorized health care provider.

(21) "Parent" means the individual who has legal custody of the child.

(22) "Program" means a community-based substance use disorder inpatient and residential facility.

(23) "Treatment plan" means a written document identifying the clinical needs, goals, objectives, and interventions the client agrees to follow to help the client understand and meet these treatment objectives.

AUTH: 50-5-103, 53-24-208, 53-24-301, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 76-2-411, MCA

NEW RULE III POLICY AND PROCEDURE MANUAL REQUIREMENTS

(1) Each service provider must develop and implement a policy and procedure manual that includes:

(a) the philosophy of the program;

(b) the program goals;

(d) procedures governing the treatment and care of adolescents, if served in the program;

(e) a delineation of all of the services to be provided;

(f) identification or a description of critical populations and mechanisms to address their needs;

(g) admission criteria which shall include at a minimum:

(i) how admissions will be prioritized;

(ii) program limitations and exclusions;

(iii) methods to be followed when a person is found ineligible for services; and

(iv) steps to follow for a wait list that includes how interim services will be provided when appropriate.

(h) procedures outlining how facilities and services shall provide for privacy and separation by gender;

(i) organizational chart showing:

(i) the lines and delegation of authority with supervisory responsibility clearly identified; and

(ii) responsibilities, structure, and reporting relationships explicitly stated and all staff positions delineated and functions identified.

(j) implementation process of state and federal regulations on client confidentiality, including at a minimum:

(i) providing written summary and verbal confidentiality notification at the time of admission or as soon thereafter as the client is capable of rational communication. The minimum required elements of the written summary must include but are not limited to the following:

(A) a general description of the limited circumstances under which a program may acknowledge that an individual is present at a facility or disclose outside the program information identifying a patient as an alcohol or drug abuser;

(B) a statement that information related to a patient's commission of a crime on the premises of the program or against personnel of the program is not protected; and

(C) a statement that reports of suspected child abuse or neglect made under state law to appropriate state or local authorities are not protected.

(k) a client grievance process;

(l) reporting requirements to notify the department within 24 hours by e-mail or fax; of a client, staff, volunteer, or visitor death where the death occurs on-site or in service related activities;

(m) reporting requirements to notify the department within 24 hours or next business day of any fire, accident, or other incident resulting in significant damage to the service site;

(n) reporting any suspected abuse or neglect in accordance with 41-3-201 or 52-3-811, MCA, to the state child abuse hotline at (866) 820-5437;

(o) notification of the department's licensing bureau in writing within 24 hours of any allegations of client abuse including child abuse or neglect and elder abuse or neglect:

(i) the provider must indicate in writing that the proper authorities have been contacted and the abuse or neglect reported.

(p) steps to ensure smoking is not permitted per the Montana Clean Indoor Air Act;

(q) the management, storage, and disposal of prescription and over the counter drugs if applicable; and

(r) client transportation, if provided by facility.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-207, 53-24-208, 53-24-306, 76-2-411, MCA

NEW RULE IV AGENCY ADMINISTRATOR RESPONSIBILITIES (1) The agency administrator is responsible for and must be familiar with daily operation of the facility.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-301, MCA

NEW RULE V REQUIREMENTS FOR THE PERSONNEL MANUAL (1) The program shall have written personal policies including the following:

(a) selection, training, and supervision of all personnel;

(b) maintaining a current job description for each position. For contract staff, formal agreements or personnel contracts, which describe the nature and extent of client care services, may be substituted for job descriptions;

(c) maintaining a process governing volunteer (if utilized) activities and establishing appropriate training requirements;

(d) assuring annual performance reviews for all staff;

(e) actions to be taken if staff members misuse alcohol or other drugs;

(f) assuring staff orientation prior to assumption of duties including but not limited to:

(i) defining staff ethical standards and conduct, including reporting of unprofessional conduct to appropriate authorities;

(ii) staff grievance procedures;

(iii) the facility disaster/evacuation plan;

(iv) review of policy and procedure manual; and

(v) review of client rights as defined in [NEW RULE IX].

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, MCA

NEW RULE VI PERSONNEL FILE REQUIREMENTS (1) The administrator or designee must ensure there is a current secured personnel file for each employee, trainee, student, and volunteer, and for each contract staff person who provides or supervises client care. The file must include:

(a) the results of a tuberculin test upon employment and annually thereafter;

(b) a criminal justice information network (CJIN) background information check on each staff person having direct contact with clients;

(c) evidence that all staff have current and valid certification in cardio-pulmonary resuscitation (CPR) and in first aid techniques;

(d) an annual performance review that is:

(i) conducted by the appropriate supervisor of each staff member; and

(ii) signed and dated by the employee and supervisor.

(e) copies of registration or licensure applicable to employee's job duties;

(f) evidence of an independent contractor status and contractual agreements for interns and contracted personal;

(g) a signed statement acknowledging the employee has been oriented and agrees to abide by confidentiality requirement to maintain confidentiality of client information;

(h) resume or job application;

(i) disciplinary actions and grievances; and

(j) a copy of a current job description, signed and dated by the employee and supervisor which includes:

(i) job title;

(ii) minimum qualifications for the position; and

(iii) summary of duties and responsibilities.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, MCA

NEW RULE VII REQUIREMENTS FOR TRAINING OR VOLUNTEER PROGRAMS (1) If programs participate in a trainee/intern practicum or have volunteers, they must have the following:

(a) policies and practices assuring the safety of clients;

(b) a description of the program and any limitations;

(d) policies and practices to assure volunteers meet the qualifications of the position to which the person is assigned; and

(e) a written agreement with each educational institution using the treatment agency as a setting for student practice to include but not limited to:

(i) a description of the nature and scope of student activity at the treatment settings; and

(ii) a plan for supervision of student activities.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, MCA

NEW RULE VIII CLINICAL REQUIREMENTS (1) At a minimum, the program is required to have written policies and procedures including supporting evidence of implementation on each of the following areas:

(a) staffing requirements to include assurance there is an identified clinical supervisor who is a licensed addiction counselor and oversees the implementation of services to assure quality and appropriateness of care rendered to clients;

(b) critical population requirements to include how pregnant woman resources and referral options will be made available so staff can make referrals as indicated by client needs including:

(i) ensuring a pregnant woman who is not seen by a private physician, physician assistant-certified, nurse practitioner, or advanced practice registered nurse is referred to one of these providers for determination of prenatal care needs; and

(ii) discussing pregnancy specific issues and resources.

(i) ensuring utilization of the DSM and the ASAM admission, continued stay, and discharge criteria for patient placement decisions in the initial and the ongoing assessment of the client throughout the course of treatment;

(ii) ensuring a person needing detoxification will be immediately referred to a detoxification provider, if available, unless the person needs acute care in a hospital; and

(iii) limitations and requirements of group counseling sessions to include client/staff appropriate for the level of care being rendered.

(d) clinical policies addressing:

(i) the assignment of work to a client by a licensed addiction counselor when the assignment is part of the treatment program and has therapeutic value;

(ii) the use of self-help groups;

(iii) arranging for medical consultation when clinically needed;

(iv) arranging for psychiatric consultation when clinically indicated;

(v) how laboratory testing is to be done including but not limited to:

(A) testing methods (urine, saliva, blood, breath, etc.); and

(B) collection and storage.

(vi) how drug and alcohol screening testing is to be done including but not limited to:

(A) a guide how testing is used as part of the therapeutic process in a nonpunitive manner;

(B) requirements to ensure the use of drug testing becomes part of the clients treatment plan; and

(e) policies addressing a facility's ability to provide dual diagnosis services to include at a minimum the following:

(i) mental health screening; and

(ii) procedures to assure mental health treatment if identified as a co-occurring client.

(f) a description of services showing there are arrangements in place for coordination and collaboration to provide services with the following, at a minimum, if not provided on-site:

(i) mental health services;

(ii) pregnancy services;

(iii) human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) services;

(iv) tuberculosis (TB) services;

(v) Hepatitis B and C services; and

(vi) sexually transmitted diseases treatment services.

(g) case management services policies and procedures provided in conjunction with or as part of the client's substance use disorder treatment and recovery;

(h) treatment planning process policies and procedures including but not limited to:

(i) how a treatment plan will be jointly developed with the client and the staff who has responsibility for the client;

(ii) assurance the treatment plan is initiated by the third contact visit for outpatient services and within three days of admission for residential services;

(iii) a provision for review and signature by the client and the staff person providing treatment services to the client;

(iv) documentation of regular reviews of the treatment plan with the client in the progress notes;

(v) having measurable objectives and therapeutic interventions with target dates appropriate to the client's clinical needs;

(vi) the clinical problems identified in the client's biopsychosocial assessment;

(vii) when clinically appropriate, implementing a targeted case management plan;

(viii) the engagement or disengagement and documentation of family members and significant others involvement and participation in the treatment process including but not limited to:

(A) offering family sessions and regularly scheduled group and educational activities for family members and significant others; and

(B) how clinical decisions are made and documented regarding the need to involve or not to involve the family and significant others in the treatment process.

(ix) how the facility will conduct reviews as part of a multidisciplinary staffing and how documentation in the client record will reflect all staff who participated in the review;

(x) documenting patient response to treatment and achievement of the treatment plan objectives in the progress notes; and

(xi) a policy to assure the client has a continuing care plan prior to discharge which at a minimum addresses:

(A) support group recommendations;

(B) continuing care service provider's contact name, contact number, and initial appointment;

(D) goals for continuing care.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-207, 53-24-208, 76-2-411, MCA

NEW RULE IX CLIENT RIGHTS POLICIES AND PROCEDURES (1) At a minimum the program is required to have written policies and procedures including supporting evidence of implementation of each of the following items:

(a) clients are admitted to treatment without regard to race, color, creed, national origin, religion, sex, sexual orientation, age, or disability, except for bona fide program criteria;

(b) clients are reasonably accommodated in case of sensory or physical disability, limited ability to communicate, limited English proficiency, or cultural differences;

(d) all clinical and personal information is treated in accordance with state and federal confidentiality regulations;

(e) clients have the opportunity to review their own treatment records in the presence of the administrator or designee;

(f) clients are fully informed of fees charged, including fees for copying records to verify treatment and methods of payment available;

(g) clients are protected from abuse, harassment, and exploitation by staff or from other clients who are on agency premises;

(h) clients will receive a copy of client grievance procedures describing the submission and disposition of complaints by client and right to appeal without threat of reprisal;

(i) client consent must be obtained for each release of information to any other person or entity. This consent for release of information must include:

(i) name of the consenting client;

(ii) name or designation of the provider authorized to make the disclosure;

(iii) name of the person or organization to whom the information is to be released;

(iv) nature and limits of the information to be released;

(v) purpose of the disclosure, as specific as possible;

(vi) specification of the date or event on which the consent expires;

(vii) statement that the consent can be revoked at any time, except to the extent that action has been taken in reliance on it;

(viii) signature of the client or parent, guardian, or authorized representative, when required, and the date; and

(ix) a statement prohibiting further disclosure unless expressly permitted by the written consent of the person to whom it pertains.

(j) in the event of a program closure or treatment service cancellation, each client must be:

(i) given 30 days notice;

(ii) assisted with relocation into similar treatment services;

(iii) given refunds to which the person is entitled; and

(iv) advised how to access records to which the person is entitled.

(k) the provider must post a copy of clients' rights in a conspicuous place in the facility accessible to clients and staff; and

(l) client orientation to program rules, responsibilities, and any sanctions that may be imposed for failure to comply with the program's rules.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-306, 76-2-411, MCA

NEW RULE X CLIENT RECORD MAINTENANCE AND SYSTEM REQUIREMENTS (1) Each service provider must have a comprehensive client record system maintained in accord with recognized principles of health record management. The service provider must ensure:

(a) a designated individual is responsible for the record system;

(b) a secure storage system which protects active and inactive files from damage;

(i) who has access to records;

(ii) content of active and inactive client records;

(iii) a systematic method of identifying and filing individual client records so each can be readily retrieved;

(iv) assurance each client record is complete and authenticated by the person providing the observation, evaluation, or service;

(v) retention of client records for a minimum of six years three months after the discharge or transfer of the client; and

(vi) procedures for destruction of client records.

(d) procedures for maintaining electronic client records (if applicable).

(2) In case of an agency closure, the provider closing its treatment agency must arrange for continued management of all client records. The closing provider must notify the department in writing of the mailing and street address where records will be stored and specify the person managing the records. The closing provider may:

(a) continue to manage records and give assurance they will respond to authorized requests for copies of client records within a reasonable period of time;

(b) transfer records of clients who have given written consent to another certified provider;

(c) enter into a service organization agreement with a state approved chemical dependency provider to store and manage records, when the outgoing provider will no longer be a business and provide a copy of the agreement to the department.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-306, 76-2-411, MCA

NEW RULE XI CLIENT RECORD CONTENT REQUIREMENTS (1) The service provider must ensure client record content includes:

(a) demographic information;

(b) a substance related disorder diagnosis and supporting documentation for diagnosis;

(d) documentation the client was informed of federal confidentiality requirements and received a copy of the client notice;

(e) assurance all clients have an orientation to the program's treatment services, infectious disease information, and disaster plan;

(f) voluntary consent to treatment signed and dated by the client or legal guardian;

(g) treatment plan;

(h) progress notes;

(i) discharge summary;

(j) medication records, if applicable;

(k) laboratory reports, if applicable;

(l) properly completed authorizations for release of information;

(m) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and

(n) documentation showing client received a copy of client grievance policies and procedures.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XII QUALITY MANAGEMENT REQUIREMENTS (1) The program shall have a quality management committee representative of administration and staff.

(2) The quality management committee is responsible for:

(a) developing a written plan for a continuous quality improvement program organization wide;

(b) implementing the quality improvement plan and monitoring the quality and appropriateness of services;

(d) identifying problems, taking corrective action as indicated, and monitoring results of those actions; and

(e) at least annually, reviewing and updating the quality improvement plan.

(3) The quality improvement program must at a minimum include but not be limited to:

(a) administrative processes;

(b) fiscal processes;

(d) client outcomes.

AUTH: 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 76-2-411, MCA

NEW RULE XIII REQUIRED OUTCOME MEASURES (1) At a minimum, the quality management committee must monitor:

(a) services to critical populations including priority in the following order:

(i) pregnant injecting drug users;

(ii) pregnant substance abusers.

(b) injecting drug users and those individuals infected with the etiologic agent for AIDS;

(d) clients receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI);

(e) homeless clients; and

(f) aging clients.

(2) Outcome evaluations shall include but not be limited to the following measures:

(a) abstinence and reduction of the use of alcohol and other drugs;

(b) decreased involvement with the criminal justice system;

(d) safe stable housing;

(e) social connectedness and supports;

(f) retention in treatment and early unplanned discharges;

(g) increased access to treatment services;

(h) clients perception of care;

(i) cost effectiveness of the program; and

(j) use of evidence-based practices.

(3) Programs must collect outcome data at:

(a) admission and discharge; and

(b) six months and one year after discharge.

(i) If unsuccessful in follow up for the six-month and one-year measurement, documentation must be provided as to reason for no follow up data.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 76-2-411, MCA

NEW RULE XIV FACILITY REQUIREMENTS (1) The administrator is responsible for the overall management of the program facility(s).

(2) Building requirements include but are not limited to the following:

(a) facilities must be accessible to a person with a physical disability. If a facility is unable to provide access to an individual with a physical disability, the program must make arrangements for a referral or other accommodations to assure the person receives appropriate services;

(b) facilities must meet all applicable building and fire codes and be approved by the authority having jurisdiction to determine if the appropriate building and fire codes are met;

(c) a patient or resident may not be admitted, housed, treated, or cared for in an addition or altered area until the area is inspected and approved by the department or in new construction until licensed by the department;

(d) facilities must be constructed and maintained in a manner to prevent entrance and infestation by rats, mice, insects, flies, or other vermin; and

(e) providers must ensure each facility, exterior grounds, and component parts such as but not limited to fences, equipments, outbuildings, and landscape items are safe, free of hazards, clean, and maintained in good repair.

(3) Water supply, sewage, and waste disposal requirements include but are not limited to the following:

(a) facilities must meet water and sewer system requirements of the municipality or jurisdiction in which it is located;

(b) hot water temperatures supplied to hand washing and bathing facilities must not exceed 120ºF;

(c) garbage and refuse must be kept in durable, easily cleanable, insect and rodent proof containers that do not leak and do not absorb liquids. Plastic bags and wet strength paper bags may be used to line these containers;

(d) refuse and recycling containers stored outside the residence, dumpsters, compactors, and compactor systems must be easily cleanable, must be provided with tight-fitting lids, doors, or covers, and shall be kept covered when not in actual use;

(e) containers designed with drains must have drain plugs in place at all times, except during cleaning; and

(f) garbage and refuse must be disposed of daily and removed from the property at least weekly to prevent the development of odor and attraction of insects and rodents.

(4) Physical environmental requirements include but are not limited to the following:

(a) deodorants may not be used for odor control in lieu of proper ventilation; (b) all operable windows must have a screen in good repair;

(d) each room or area occupied by children under age five or residents with unsafe behaviors must have tamper resistant electrical outlets;

(e) facilities must have adequate private space for personal consultation with a client, staff charting, and therapeutic and social activities, as appropriate;

(f) all electrical, mechanical, plumbing, fire protection, heating, and sewage disposal systems must be kept in operational condition;

(g) each facility must have an annual inspection by the local fire authority;

(h) each facility must have floors covered with an easily cleanable surface; and

(i) all walls and ceilings, including doors, windows, skylights, and similar closures must be maintained in good repair.

(5) Laundry requirements include but are not limited to the following:

(a) the program must ensure that laundry facilities, equipment, and laundry handling and processes will ensure linen and laundered items provided to residents are clean, in good repair, and adequate to meet the needs of residents.

(6) Bedding and linen requirements include but are not limited to the following:

(a) the program must ensure bedding and linen provided to residents are clean, in good repair, and adequate to meet the needs of residents including but not limited to:

(i) assuring each resident has a bed, a moisture-proof mattress cover, and mattress pad in good condition; and

(ii) assuring the facility or resident keep a supply of:

(A) clean bed linen on hand sufficient to change beds often enough to keep them clean, dry, and free from odors;

(B) clean individual towels and washcloths; and

(7) Bathroom requirements include but are not limited to the following:

(a) the provider must ensure private or common-use toilet rooms and bathrooms are available to residents including the provision for:

(i) a minimum of one toilet and hand washing sink for every four residents, or fraction thereof;

(ii) a sink is located in or immediately accessible to each toilet room;

(iii) a minimum of one bathing fixture for every six residents;

(iv) hand cleansing soap or detergent must be available at each lavatory in the facility. The use of a communal bar soap is prohibited;

(v) provision for individual towels must be available at each lavatory; and

(vi) a waste receptacle must be located near each lavatory.

(8) Bedroom requirements include but are not limited to the following:

(a) the program shall ensure residents have an accessible, clean, well-maintained room with sufficient space and light for sleeping and personal activities including but not limited to ensuring:

(i) bedrooms are at least 60 square feet per person in a multiple person room except where construction or cost would be prohibitive;

(ii) direct access to a hallway, living room, lounge, the outside, or other common use area without going through a laundry or utility area, a bath or toilet room, or another resident's bedroom;

(iii) each bedroom has one operable outside window with visual privacy; and

(iv) each bedroom is equipped with:

(A) a bed;

(B) one or more noncombustible waste containers; and

(9) Disaster plan requirements include but are not limited to the following:

(a) each facility must have an evacuation and disaster plan;

(b) there must be a fire evacuation plan for use in the event of a fire, addressing:

(i) a procedure for accounting for all residents and staff during and after the emergency and the meeting location after evacuation; and

(ii) making provisions for emergency medications, food, water, clothing, shelter, heat, and power.

(c) the posting of evacuation routes on the premises where services are being provided in a place where they can be easily viewed by clients, participants, and staff; and

(d) the program must conduct and document a drill of the fire and evacuation plan at least once a year.

(10) Infectious disease prevention and control requirements include but are not limited to the following:

(a) a program shall develop and follow a written infection control plan for both staff and clients, including but not limited to:

(i) implementation of universal precautions for communicable diseases; and

(ii) provision for patient and staff education necessary to implement infection control policies and procedures.

(11) Emergency procedure requirements include but are not limited to the following:

(a) facilities must have written procedures to be followed in the event of a medical or other emergency;

(b) poison control and emergency contacts must be posted at the telephone; and

(12) Facility maintenance requirements include but are not limited to the following:

(a) each facility shall have evidence of a maintenance program and procedures that are utilized to keep the building and equipment in good repair and free from hazards;

(b) facilities must assure adequate housekeeping services, procedures, and or supplies are available to assure a clean, safe, and sanitary environment in all areas of the facility;

(d) facilities must use a dishwasher or use hot soapy water for hand washed utensils, dishes, and equipment.

(13) Pest control requirements include but are not limited to the following:

(a) effective measures intended to minimize the presence of rodents, flies, cockroaches, and other vermin on the premises;

(b) measures to ensure containers of poisonous and toxic materials be stored safely and bear a legible manufactures label or Material Safety Data (MSD) sheets; and

(14) Food and nutrition requirements include but are not limited to the following:

(a) the program must ensure resident food preparation, handling, and storage is adequate to meet the needs of residents including but not limited to the following:

(i) food must be stored in a clean, dry location where it is not exposed to contamination;

(ii) conveniently located refrigeration facilities or effectively insulated facilities must be provided to assure maintenance of potentially hazardous food;

(iii) food that isn't stored in original containers must be dated, labeled, and covered;

(iv) food cannot be stored on the floor;

(v) refrigerated foods must be maintained at a temperature of 41 to 44ºF;

(vi) frozen foods must be kept frozen;

(vii) raw fruits and vegetables must be thoroughly washed in potable water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in ready-to-eat form;

(viii) all home canned products are prohibited;

(ix) sinks used for preparation of foods must be cleaned and sanitized;

(x) food preparers shall wash their hands before engaging in food preparation, and during preparation as often as necessary to remove soil and contamination, and to prevent cross contamination when changing tasks; and

(xi) food preparers and other authorized persons shall maintain a high degree of personal cleanliness and shall conform to good hygiene practices during food preparation.

(15) Pet management requirements include but are not limited to the following:

(a) facilities are allowed to have pets in residence based upon facility policy and ensuring all animals are current on vaccinations.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 76-2-411, MCA

NEW RULE XV INPATIENT SERVICE REQUIREMENTS (1) To be licensed to provide freestanding adult and adolescent medically monitored intensive inpatient ASAM Level III.7 substance related disorders treatment services, a provider must meet the following:

(a) staffing requirements include but are not limited to the following:

(i) a physician, nurse practitioner, or physician assistant licensed under Title 37, MCA, to conduct a physical examination and screening of a client within 24 hours of the person's admission to a service to identify health problems and screen for communicable diseases;

(ii) a nurse licensed under Title 37, MCA, on-site or on call 24 hours a day, seven days a week; and

(iii) a physician licensed under Title 37, MCA, available to provide medical consultation either as an employee of the service or through written agreement.

(b) service requirements include but are not limited to the following:

(i) family services are made available;

(ii) direct affiliation with an acute care hospital; and

(iii) daily scheduled professional services; such services must include and are not limited to medical services and medication management, individual, group, family, and educational services.

(c) if community-based day treatment services as defined in ASAM are provided, there must be access to services provided under ASAM Level III.7.

(2) To be licensed to provide community-based residential program for adults and adolescents with ASAM Level III.5 substance use disorders, a provider must meet the following:

(a) staffing requirements include but are not limited to the following:

(i) a licensed physician, physician assistant, nurse practitioner, or registered nurse as defined as a licensed health care professional in 50-5-101, MCA, to conduct an assessment and evaluation of a client within 72 hours of admission to service; and

(ii) a nurse licensed under Title 37, MCA, on-site, on call, or access to medical services 24 hours a day, seven days a week.

(b) service requirements including the following program policies must address:

(i) how the programs treat persons with substance use disorders and related problems;

(ii) admission criteria to include service limitations; and

(iii) daily scheduled professional services, such services may include but not be limited to medical services, nursing services, individual and group counseling, psychotherapy, family therapy, educational groups, occupational and recreational therapies, art, music, or movement therapies, physical therapy, and vocational rehabilitation activities.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XVI COMMUNITY-BASED SOCIAL DETOXIFICATION PROGRAM REQUIREMENTS (1) The most intensive level of care, outside of an acute care hospital, is defined as medically monitored care to clients whose withdrawal symptoms are sufficiently severe to require 24-hour inpatient care with observation, monitoring, and treatment available and delivered by a multidisciplinary team including 24-hour nursing care under the supervision of a Montana licensed physician.

(2) To be licensed to provide medically monitored detoxification (ASAM Level III.7), a provider must meet the following:

(a) facility requirements include but are not limited to the following:

(i) the facility shall be equipped for clients who are impaired due to substances and who require safety rails on beds, handrails on showers, and other related equipment to assure the safety of impaired clients; and

(ii) oxygen or other emergency equipment according to the physician-prescribed protocols for responding to client health emergencies.

(b) staffing requirements include but are not limited to the following:

(i) a physician licensed under Title 37, MCA, available on call 24 hours a day, 7 days a week to evaluate clients and prescribe medications;

(ii) staff available in sufficient numbers and trained to respond to substance-related and co-occurring disorders of admitted clients;

(iii) a registered nurse licensed under Title 37, MCA, who is responsible for the supervision of nursing staff and the administration of detox protocols; and

(iv) support staff such as licensed practical nurses, certified nurse assistants, rehabilitation aides etc. in sufficient numbers to assure the safety of clients.

(i) a written agreement with a state approved chemical dependency treatment facility to provide ongoing care following client discharge from the detoxification service;

(ii) there shall be a discharge note that addresses the referral and service needs of the client for follow-up treatment or care;

(iii) medication administration and on-going assessment of the client which are documented in the client record;

(iv) written medication orders specifying the name, dose, and route of administration signed by the prescribing physician;

(v) meals and snacks in sufficient quantities to assure the nutritional needs of the clients are met; and

(vi) written policies and procedures specifying how the facility will provide for the transfer of patients when indicated, to an acute care hospital.

(3) To be licensed to provide community-based social detoxification as defined as ASAM Level III-D, III.2-D, and III.7-D for individuals with substance use disorders as defined by ASAM, a provider must meet the following:

(a) facility requirements include but are not limited to the following:

(b) staffing requirements include but are not limited to the following:

(i) physician approved protocols for the monitoring of clients in withdrawal including when and under what circumstances clients should be transferred to a health care facility;

(ii) a written agreement with the health care facility or physician providing for emergency services when needed;

(iii) written procedures specifying how staff will respond to emergencies and for the transfer of medically unstable patients;

(iv) sufficient staff on duty trained in CPR and the detox protocols on each shift to be followed to assure clients safe withdrawal from substances; and

(v) if medications are provided, there is a current prescription in the client's name and staff are trained in medication administration procedures which are documented in policies and procedures.

(i) an initial physical examination by a qualified professional that assures the client can be safely detoxified in a nonmedical setting and documented in the client record;

(ii) regular vital signs are taken and recorded by staff trained to recognize symptoms indicating the client is becoming physically unstable;

(iii) meals and snacks in sufficient quantities to meet the nutritional needs of the client;

(iv) there shall be a written discharge plan that assures necessary referrals and continuing treatment services;

(v) all entries in the client record will be signed and dated by staff providing the service; and

(vi) a written agreement with an approved addiction treatment provider assuring acceptance of client for treatment upon discharge from the detoxification service.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XVII HALFWAY HOUSE COMMUNITY-BASED RESIDENTIAL PROGRAM REQUIREMENTS (1) Halfway house community-based residential programs consist of the following program settings:

(a) halfway house community-based parent and children residential homes (ASAM Level III.3 high intensity treatment);

(b) halfway house community-based single gender homes (ASAM Level III.5 high intensity treatment);

(d) halfway house community-based single gender residential homes (ASAM Level III.1 low intensity treatment). This treatment level is also known as sober housing.

AUTH: 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XVIII HALFWAY HOUSE COMMUNITY-BASED PARENT AND CHILDREN RESIDENTIAL HOMES (ASAM LEVEL III.3 – MEDIUM INTENSITY)

(1) The community-based parent and children residential homes for individuals with substance use disorders serve parent(s) with dependent child(ren) who are in need of 24-hour supportive housing while undergoing on- or off-site treatment services for substance use disorder and life skills training for independent living. To be licensed to provide community-based parent and children residential homes for individuals with substance use disorders ASAM Level III.3 medium intensity treatment, a provider must meet the following:

(a) 24-hour staffing patterns to afford sufficient security to assure the safety of residents, staffing requirements may include but are not limited to:

(i) licensed addiction counselor (LAC);

(ii) individuals trained in managing co-occurring disorders;

(iii) case managers that have a minimum of two years of higher education and orientation to the facilities policies and procedures; and

(iv) rehabilitation aides that have a minimum of a high school diploma or GED and orientation to the facilities policies and procedures.

(b) service requirements including but not limited to the following program policies must address:

(i) the delivery of ASAM Level III.3 treatment services either on- or off-site;

(ii) admission criteria indicating individuals appropriate for these settings;

(iii) how the treatment needs of both the parent(s) and child(ren) are identified and addressed;

(iv) how life skills training is provided as part of the daily living regimen and includes a curriculum to address independent living skills, vocational skills, and parenting skills;

(v) how services are coordinated to meet special needs of this population such as childcare, legal services, medical care, and transportation;

(vi) how age appropriate services are made available for children as needed;

(vii) assurance of a single gender of parent will be living at the facility;

and

(viii) assurance for safe visitation.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XIX HALFWAY HOUSE SINGLE GENDER RESIDENTIAL HOMES (ASAM LEVEL III.5 – HIGH INTENSITY) (1) The community-based single gender residential homes for individuals with substance use disorders serve individuals who are in need of 24-hour supportive housing while undergoing on- or off-site treatment services for substance use disorder and life skills training for independent living. To be licensed to provide community-based single gender residential homes for individuals with substance use disorders ASAM Level III.5 high intensity treatment, a provider must meet the following:

(a) 24-hour staffing patterns to afford sufficient security to assure the safety of residents, staffing requirements may include but are not limited to:

(i) licensed addiction counselor (LAC);

(ii) individuals trained in managing co-occurring disorders;

(iii) case managers that have a minimum of two years of higher education and orientation to the facilities policies and procedures; and

(iv) rehabilitation aides that have a minimum of a high school diploma or GED and orientation to the facilities policies and procedures.

(b) service requirements including but not limited to the following program policies must address:

(i) the delivery of ASAM Level III.5 treatment services either on- or off-site;

(ii) admission criteria indicating individuals appropriate for these settings;

(iii) how the treatment needs are identified and addressed;

(iv) how life skills training is provided as part of the daily living regimen and includes a curriculum to address independent living skills and vocational skills;

(v) how services are coordinated to meet special needs of this population such as legal services, medical care, and transportation; and

(vi) assurance for safe visitation.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XX HALFWAY HOUSE SINGLE GENDER COMMUNITY-BASED RESIDENTIAL HOMES (ASAM LEVEL III.3 – MEDIUM INTENSITY)

(1) Community-based single gender residential homes for individuals with substance use disorders may be located in residential neighborhoods, comparable to other homes in the neighborhood, and shall reflect the environment of a home. To be licensed to provide community-based residential homes for individuals with substance use disorders ASAM Level III.3 medium intensity treatment, a provider must meet the following:

(a) staffing or security measures sufficient to assure the safety of residents, staffing requirements may include but are not limited to:

(i) licensed addiction counselor (LAC);

(ii) individuals trained in managing co-occurring disorders;

(iii) case managers that have a minimum of two years of higher education and orientation to the facilities policies and procedures;

(iv) rehabilitation aides that have a minimum of a high school diploma or GED and orientation to the facilities policies and procedures.

(b) service requirements including but not limited to the following program policies must address:

(i) these homes as transitional versus permanent living environments and how they provide interim supports and services for persons with substance use disorders and related problems;

(ii) admission criteria indicating that the individual is appropriate for these settings;

(iii) define the criteria for the length of stay in the facilities;

(iv) how clinical treatment is provided either on- or off-site; and

(v) how life skills training including vocational services is incorporated into daily residential living to prepare residents to assume permanent housing and independent living.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

NEW RULE XXI HALFWAY HOUSE COMMUNITY-BASED SINGLE GENDER RESIDENTIAL HOMES (ASAM LEVEL III.1 – LOW INTENSITY) (1) The single gender facility functions as a safe, alcohol and drug-free environment for individuals in early stages of recovery from substance use disorders or individuals who are transitioning to less intensive levels of treatment services and in need of such housing. To be licensed to provide community-based residential sober housing homes for individuals with substance use disorders ASAM Level III.1 low intensity treatment, a provider must meet the following:

(a) staffing or security measures sufficient to assure the safety of residents, staffing requirements may include but are not limited to:

(i) licensed addiction counselor (LAC);

(ii) individuals trained in managing co-occurring disorders;

(iii) case managers that have a minimum of two years of higher education and orientation to the facilities policies and procedures; and

(iv) rehabilitation aides that have a minimum of a high school diploma or GED and orientation to the facilities policies and procedures.

(b) service requirements including but not limited to the following program policies must address:

(i) admission and length of stay criteria defining individuals appropriate for this setting;

(ii) how all treatment and supportive services are generally off-site in community-based agencies; and

(iii) assurance the program is designed and focused on helping individuals with limited life skills and generally focus on helping individuals achieve employment, maintain a daily schedule of work, support group meetings, assigned treatment sessions, and learning how to cooperate and assume responsibility in a community setting.

AUTH: 50-5-103, 53-24-208, MCA

IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

4. The department proposes to repeal the following rules:

37.27.128 DETOXIFICATION (EMERGENCY CARE) COMPONENT REQUIREMENTS, is found on page 37-5879 of the Administrative Rules of Montana.

AUTH: 53-24-204, 53-24-208, MCA

IMP: 53-24-208, MCA

37.27.129 INPATIENT - HOSPITAL COMPONENT REQUIREMENTS, is found on page 37-5887 of the Administrative Rules of Montana.

AUTH: 53-24-204, 53-24-208, MCA

IMP: 53-24-208, MCA

37.27.130 INPATIENT - FREE STANDING CARE COMPONENT REQUIREMENTS, is found on page 37-5897 of the Administrative Rules of Montana.

AUTH: 53-24-204, 53-24-208, MCA

IMP: 53-24-208, MCA

37.27.135 INTERMEDIATE CARE (TRANSITIONAL LIVING) COMPONENT REQUIREMENTS, is found on page 37-5909 of the Administrative Rules of Montana.

AUTH: 53-24-204, 53-24-208, MCA

IMP: 53-24-208, MCA

5. The Department of Public Health and Human Services (the department) is proposing the adoption of New Rules I through XXI because there are currently no rules addressing the licensing requirements for community-based substance use disorder inpatient and residential halfway house treatment facilities. These proposed new rules were developed through a collaborative effort of the department's Quality Assurance Division and Addictive and Mental Disorders Division, and numerous community-based substance use disorder treatment providers.

The inpatient rules currently found in ARM 37.27.129 and 37.27.130 and the transitional living facility rule in ARM 37.27.135 were written over 25 years ago and are inadequate to address the current level of services needed in halfway house treatment facilities. The group that developed these rules agreed that ARM 37.27.135 did not adequately address all American Society of Addiction Medicine (ASAM) levels of residential treatment, therefore the department is proposing adopting New Rules I through XXI and repealing ARM 37.27.128, 37.27.129, 37.27.130, and 37.27.135.

The department's Addictive and Mental Disorders Division has been and is currently contracting with all types of facilities that provide the services these proposed rules address. Community-based substance use disorder residential house treatment facilities currently have no administrative rules to follow, only contract language to address what rules should address. Therefore, these rules are necessary to direct licensees and the department in providing appropriate regulation for community-based substance use disorder inpatient and residential house the treatment facilities.

Previously, there was one rule to address transitional living facilities located in ARM 37.27.135. It did not give authority for licensure to the appropriate division within department. The proposed adopted new rules would fall under the authority of the health care facility statutes and authority found at 50-5-101(10), 50-5-103(1), and 76-2-411(3), MCA. Section 76-2-411(3), MCA identifies "a halfway house operated in accordance with regulations of the Department of Public Health and Human Service for the rehabilitation of alcoholics or drug dependent persons" as a community residential facility. This section in conjunction with the previously mentioned sections is the basis for the authority to license these facilities under Title 50, chapter 5.

The proposed new rules are described below.

New Rule I

Proposed New Rule I describes the purpose of the proposed new subchapter and contains instructions on interpretation when rules in the subchapter are in conflict with general rules on standards for health care facilities.

Proposed New Rule I also provides a current list of ASAM Residential Levels of Care as follows:

A. Level III.1 Clinically Managed Low-Intensity Residential Treatment

B. Level III.3 Clinically Managed Medium-Intensity Residential Treatment

C. Level III.5 Clinically Managed High-Intensity Residential Treatment

D. Level III.7 Medically Monitored Inpatient Treatment

This is a nationally accepted description and individual determination of treatment need. The proposed new rule identifies the types of facilities that would be able to provide services under these rules in halfway house settings.

New Rule II

It is necessary to define terms that are used within these rules for purposes of common language and understanding throughout all of these rules. The general public and those providing and receiving treatment need to have a clear understanding of terminology used within the substance use disorder treatment field as well as specific descriptions/meanings of words used throughout these rules.

New Rule III

This proposed new rule is needed to address general overall operational guidance. Facilities need to clearly define services to be provided, clientele eligibility, and any limitations in the operation of the facility before they can provide daily residential treatment services.

New Rule III(1)(a) through (h)

These new rules are needed to address general overall operation guidelines for facility treatment and capacity to provide specific types of residential substance use disorder treatment services to those in need. This provides protection for both the facility and those seeking services because facilities must clearly define daily operations and all services to be provided before being licensed.

New Rule III(1)(i)

The organization chart is important to clearly demonstrate to personnel, clients, and the public there is a structure in place in each facility to address safety, lines of authority and responsibility, and types of services that could be part of that inpatient and residential halfway house treatment facility.

New Rule III(1)(j)

Provisions for client confidentiality are necessary to provide both staff and client guidance to what type of information is protected and procedures to obtain or release client information. These provisions protect the client by not releasing confidential information obtained during the assessment and treatment process. These provisions protect facility staff by providing guidance regarding the client information that can or cannot be disclosed.

New Rule III(1)(k)

The client grievance procedure is necessary to inform clients of their rights while in residential treatment and the process to follow if they believe those rights are violated. This gives the facility the right to manage grievances and termination of services.

New Rule III(1)(l) through (n)

Reporting requirements are necessary to provide the state with adequate information regarding the operational status of the inpatient and residential halfway house treatment facility and any suspected harm clients may have experienced while in residential treatment.

New Rule III(1)(o)

Reporting requirements are necessary to provide the state with adequate information regarding any incident of child neglect or abuse or client abuse to ensure safety and protection of clients living in the inpatient and residential halfway house treatment facility.

New Rule III(1)(p)

The reference to the Montana Clean Indoor Air Act is necessary as many clients in residential treatment for alcohol or other drugs commonly use tobacco as a replacement or coping mechanism to their addiction for which they are being treated. Many residential facilities would not view themselves as a public facility therefore, this provision is necessary.

New Rule III(1)(q)

Addressing the handling of prescription drugs and over the counter drugs within the inpatient and residential halfway house treatment facility is needed to protect all clients. Many individuals addicted to other drugs may have an addiction to prescription drugs/over the counter drugs or may substitute available prescription drugs/over the counter drugs to meet their addiction needs. This requirement will also protect inpatient and residential halfway house treatment facility staff by clearly delineating procedures for handling prescription drug/over the counter drugs within the inpatient and residential halfway house treatment facility.

New Rule III(1)(r)

Transportation needs to be addressed by each inpatient and residential halfway house treatment facility in order to provide conditions to follow when clients can be transported by facility or staff's personal vehicles, when such services are available, and any associated conditions that may apply to the transportation.

New Rule IV

This proposed new rule is necessary because the inpatient and residential halfway house treatment facility may not necessarily have an on-site administrator but falls under the umbrella of a larger organization providing the same types of services. The proposed new rule will ensure the individual inpatient and residential halfway house treatment facility is provided with administrative oversight.

New Rule V

This proposed new rule is necessary to ensure inpatient and residential halfway house treatment facilities have qualified personnel providing services within each inpatient and residential halfway house treatment facility. Qualified and appropriately licensed/certified personnel are needed to protect clients within the facility during treatment services. The facility is also protected because they need to identify the qualified individuals to perform the treatment services within the inpatient and residential halfway house treatment facility.

New Rule VI

Personnel file requirements are necessary for the protection, health, and safety of clients being served within the inpatient and residential halfway house treatment facility. Staff files are protected for the same reasons as clients but additional protection is provided through staff evaluations, clearly delineated job duties, and understanding the facility orientation and rules. Confidentiality and security policy and procedures provide a standard of operating procedures for the facility.

New Rule VII

Many residential treatment facilities will use volunteers and/or individuals in training to become a professional in their field as part of treatment services. These rules provide guidance for residential treatment facilities to allow individuals, other than facility personnel, to appropriately participate in client services or treatment. These rules are needed to protect the health and safety of the clients within the inpatient and residential halfway house treatment facility by ensuring volunteers and/or individuals in training have received orientation and adequate supervision while working with clients. Volunteers and/or individuals in training are protected for the same reasons as clients but additional protection is provided through clearly delineated job duties and understanding the facility orientation and rules.

New Rule VIII

Proposed New Rule VIII is necessary to provide policy guidance in the basis of treatment protocols to follow, specific services and limitations of treatment to address, treatment planning process, and how treatment is reviewed for quality and necessity. This will protect the client because policies address the basis and necessity of treatment. The DSM and ASAM provide nationally accepted substance use disorder treatment protocols but the additional guidance provided within this rule addresses services that need to be identified/addressed to ensure a client receives individualized treatment services.

New Rule IX

Policies and procedures for client rights are necessary to provide policy guidance to facilities about the need and content for client rights. This proposed new rule identifies what types of rights or responsibilities are available to a client while participating in a treatment facility. When the client understands this information, the client will be able to properly focus on their treatment and be able to actively advocate for themselves if they believe their rights have been violated. This proposed new rule provides guidelines for staff treatment of clients, therefore protecting staff from inappropriately treating clients.

New Rule X

Proposed New Rule X provides policy guidance to residential treatment facilities regarding the collection, storage, and retention of client records, therefore protecting them by ensuring proper, secure handling of client documentation. This will protect the client by ensuring residential treatment facilities maintain records in a confidential manner and retain records for reference to treatment previously provided.

New Rule XI

Client record content requirements are necessary to provide a minimum standard of what type of information is required to complete a client record. This will protect the residential facility by ensuring the facility documents treatment provided. The client is protected because the documentation provides a basis for diagnosis and treatment and actual treatment provided.

New Rule XII

Quality management requirements provide guidance for a minimum amount of oversight and review of services being provided to individuals and facility operations. Continuous quality improvement can provide for a better quality of care. This protects the client because it ensures someone not providing direct treatment is reviewing the client's treatment process for appropriateness and outcomes. Quality improvement is a requirement of many funding sources.

New Rule XIII

Required outcome measures provide a basis for any individual, department, or agency to review the quality of treatment. This proposed new rule provides the minimum measures for residential treatment facilities to collect, therefore providing documentation on clinical outcomes of each facility. These measures are federal national outcome measures required for any federal funds dedicated to addiction treatment. Federal standards are important as approximately 80% of treatment funding is provided through federal funds.

New Rule XIV

Proposed New Rule XIV is necessary to ensure residential treatment facilities have physical settings that meet health and safety requirements within each inpatient and residential halfway house treatment facility. A safe and healthy environment is needed for protection of clients to allow him/her to focus on their treatment rather than their health and safety. The facility is also protected as a licensed facility because they must comply with minimum standards to support a safe and healthy environment so treatment services can be safely performed within the inpatient and residential halfway house treatment facility. The listed requirements are standard for any health care facility providing residential treatment services.

An inpatient and residential halfway house treatment facility may be under the jurisdiction of the local planning, zoning, and building codes. The local planning, zoning, and building code requirements are in addition to the requirements of this rule. This is necessary to ensure the safety of clients, staff, and the public by making sure the facility complies with local requirements for which the governing jurisdiction is capable of enforcing and protecting.

New Rule XV

Inpatient service is a more complex treatment modality for alcohol and drug addictions. This proposed new rule provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM Level III.7 and/or III.5 treatment services. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs of the client are addressed and provided in a safe manner. Proposed New Rule XV also provides protection for the provider by requiring a minimum level of staffing to safely address the type of treatment needed by clients.

New Rule XVI

Community-based social detoxification treatment is focused on individuals who need to be supervised while going through withdrawal from alcohol or other drugs. This is a complex treatment modality used as a step down from a hospital setting. Proposed New Rule XVI provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM Level III.7. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs for the detoxification of the client are addressed and provided in a safe manner. This proposed new rule provides protection to the provider as it outlines the minimum amount of staffing and policies needed to safely address social detoxification outside of a hospital setting.

New Rule XVII

Proposed New Rule I identifies the treatment levels of care. Proposed New Rule XVII provides a current list of what will constitute a halfway house community-based residential program. They are as follows:

A. halfway house community-based parent and children residential homes (ASAM Level III.5)

B. halfway house community-based single gender homes (ASAM Level III.5 – High Intensity)

C. halfway house community-based single gender homes (ASAM Level III.3 - Medium Intensity)

D. halfway house single gender sober housing (ASAM Level III.1 – low intensity)

This is a nationally accepted description and individual determination of treatment need. Proposed New Rule XVII identifies the types of facilities that would be able to provide services under these rules. It is necessary to identify the types of facilities eligible to provide services because it is not always appropriate to mix genders or expose family members to a specific level of care. Therefore, it is appropriate to identify the clientele to be served and the treatment level provided in a rule and then providing further descriptions about each in individual rules. This identifies for providers and clients the types of services and facilities available when accessing treatment.

New Rule XVIII

This is a complex treatment modality for alcohol and drug addictions of a parent who still has children usually under the age of 13 living with them. The complexity of treatment is still intensive but not as high as an inpatient setting of an ASAM III.7 or ASAM III.5. Proposed New Rule XVIII provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM III.3 treatment services for a parent with children. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs of the client and his/her children are addressed and provided in a safe manner. This rule also provides protection for the provider by requiring a minimum level of staffing to safely address the type of treatment needed by clients and the children being served.

New Rule XIX

This is a complex treatment modality for alcohol and drug addictions of an individual in need of high complexity of treatment modality that is still intensive but not as high as an inpatient setting of an ASAM III.7. Proposed New Rule XIX provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM III.5 treatment services for the individual. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs of the client are addressed and provided in a safe manner. Proposed New Rule XIX also provides protection for the provider by requiring a minimum level of staffing to safely address the type of treatment needed by the client. Evidence-based treatment practices have shown single gender residences are effective in achieving successful alcohol and drug treatment outcomes. Mixed gender residences often cause multiple treatment and safety issues for patients and facilities.

New Rule XX

This is a midlevel complex treatment modality for alcohol and drug addictions of an individual in need of a structured living and treatment regimen that is intensive but not as high as an ASAM III.5 home. Proposed New Rule XX provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM III.3 treatment services for the individual. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs of the client are addressed and provided in a safe manner. Proposed New Rule XX also provides protection for the provider by requiring a minimum level of staffing to safely address the type of treatment needed by the client. Evidence-based treatment practices have shown single gender residences are effective in achieving successful alcohol and drug treatment outcomes. Mixed gender residences often cause multiple treatment and safety issues for patients and facilities.

New Rule XXI

This is a low-level residential treatment modality for alcohol and drug addictions of an individual in need of a structured treatment and living situation that is still needed for a successful treatment outcome but not as high as an ASAM III.3 home. Proposed New Rule XXI provides minimum standards for required staffing, licensed practitioners, and other standardized procedures used in ASAM III.1 treatment services for the individual. These requirements are nationally accepted throughout the substance abuse treatment field and are prescriptive enough to ensure the protection and individual needs of the client are addressed and provided in a safe manner. Proposed New Rule XXI also provides protection for the provider by requiring a minimum level of staffing to safely address the type of treatment needed by the client. Evidence-based treatment practices have shown single gender residences are effective in achieving successful alcohol and drug treatment outcomes. Mixed gender residences often cause multiple treatment and safety issues for patients and facilities.

The department is proposing to repeal ARM 37.27.128, 37.27.129, 37.27.130, and 37.27.135, because the rules are outdated and do not meet the treatment needs of clients obtaining services in halfway house settings.

The department considered proposing rules that did not incorporate the ASAM treatment levels but rejected this alternative because it would allow community-based substance use disorder inpatient and residential halfway house treatment facilities too much discretion in providing treatment. By using the treatment levels, continuity of care is established and maintained. Modifying existing rules was considered but rejected because the existing rules do not address the level of care requirements necessary for community-based substance use disorder inpatient and residential halfway house treatment facilities. Modifying existing rules would be more confusing to providers.

6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail dphhslegal@mt.gov, and must be received no later than 5:00 p.m., October 21, 2010.

7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.

8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.

9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

/s/ John Koch /s/ Ann Whiting Sorrell

Rule Reviewer Anna Whiting Sorrell, Director

Public Health and Human Services

Certified to the Secretary of State September 13, 2010.