Everest Recovery will maintain administrative and assessment procedures for the admission, intake, and program orientation.

Everest Recovery associates will complete the required initial admission assessment on every potential admission and document accordingly. Every patient who is admitted will receive program orientation information.

All intake paperwork shall be completed no later than 7 days after admission unless otherwise noted.

The intake process1 will consist of:

Welcoming the patient

Reviewing and signing the following contracts and forms prior to medicating:

• Patient rights
• Confidentiality
• Consent to follow-up
• Consent to treatment
• Consent to draw blood
• Agreement to drug testing procedures
• Financial agreement
• Holiday take home screening
• HIV education form
• Insurance/payment forms
• Lockbox agreement
• Orientation to treatment form

The patient will be offered a copy of any forms they have signed

Completing the Psychosocial Assessment -General Guidelines

Assessments will be conducted by qualified persons as determined by state regulations and standards.

Assessments will be conducted in a manner that is respectful and considerate of:

• Age and Developmental Level
• Gender
• Gender Expression
• Sexual Orientation
• Social Preferences
• Cultural Background
• Psychological Characteristics
• Physical Condition
• Spiritual Beliefs

Assessments2 will include an evaluation of the following:

• Alcohol and other drug use and treatment history
• Physical health history and status, including current medications and allergies
• Psychiatric history and status, including suicide risk, previous diagnoses and treatment if any; mental status, emotional, behavioral and cognitive functioning, and current medications
• Treatment acceptance/resistance, history of participation in community support including 12-step/or other self-help programs.
• Relapse history and risk
• Recovery environment (historical life situation) including:
  • Primary supports
  • Employment/occupational
  • Social
  • Legal
  • Housing
  • Educational
  • Economic
  • Gambling history and risks
  • Cultural
  • Spiritual
  • Nutritional

Assessments will include collateral information as appropriate and permitted, including information from:

• Family members
• Health care providers
• Social service providers
• Criminal justice professionals
• Others, as necessary

Assessment information will be updated as needed

Assessments will utilize tools from ASAM (the American Society for Addiction Medicine), Adult Patient Placement Criteria, and the Diagnostic and Statistical Manual from the American Psychiatric Association. In Pennsylvania, counselors will also utilize the PCP (Pennsylvania Criteria Placement).

The intake worker will enter all essential data into the electronic medical record. This will consist of:

• DSM-V diagnosis into the computer under medical profile/view/change diagnosis screen.
• GAF score as applicable by state
• Demographics
• The patient’s 3rd party identification number as the reciprocal number

Based on the information gathered in the assessment an interpretive summary will be completed in an ASAM Patient Placement Criteria Dimension format.

The note shall include the following:

• Each dimension will be rated by risk level as outlined by the ASAM admission criteria
• The clinical impressions of the patient’s central theme
• The positive and negative factors that will influence treatment focus.
• The patients self identified strengths, needs, abilities, and preferences.

Releases of information will be signed as the need is identified throughout the assessment and treatment, as permitted in accordance with 42 CFR Part 2.

All patients will be asked to sign the following releases:

• Emergency contact release
• Release for other providers (including past treatment)
• Release for all prescribers
• Release for follow-up contact

At the time of admission, the following information will be explained to the patient:

• Orientation to the building, fire safety and exits, emergency precautions, and parking lot
• Description of the program hour’s and services
• Explanation of financial obligations, fees and financial agreement
• Counseling attendance expectations
• Patient rights, grievance, and appeal procedures.
• TB / HIV / STD information
• Program rules
• Patient Handbook
• Confidentiality / HIPAA
• Ethics
• Rules for illegal and legal drugs brought onto clinic property
• Rules for involuntary taper and administrative discharge
• Purpose and process of the bio-psychosocial assessment
• Purpose of their treatment plan

Patients will be provided with on-going information including but not limited to:

• Introduction to clinic associates and their responsibilities
• Review of ways to give input regarding quality of care (e.g., web site, newsletter, suggestion box, advocacy group), involvement of patients in outcomes management process
  • Explanation of how to access after-hours services
  • Explanation of all contracts and releases necessary for admission
  • The nature of addiction
  • The recovery process
  • Opioid treatment myths and facts

Each patient must have a physical exam prior to being medicated. Laboratory testing will include a blood drawing for screening lab work and TB skin testing, which must completed within fourteen (14) days of admission.

All patients being admitted for opioid addiction treatment must provide a urine drug screen specimen prior to beginning services. In the state of Pennsylvania drug test results must be received before services can begin.

All patients must meet criteria for eligibility and appropriateness for treatment in keeping with the Everest Recovery Admission Policy.

Dual enrollment is the process of ensuring that a patient is not enrolled in more than one MMTP program.

• Where a state registry is available the patient should be cleared through the registry and a dual enrollment form should be faxed to clinics outside of the state that are within a 50 mile radius.
• Where a state registry is not available a dual enrollment form should be faxed to all of the clinics within a 50 mile radius including other Everest Recovery clinics.

Transfer patients will have their discharge from referring OTP and last dose (amount and date) confirmed and documented in the medical record by the associate completing the confirmation.