Incidental Medical Services (IMS) Department of Health Care Services

Assembly Bill (AB) 848 AB 848 passed: October 10, 2015 AB 848 enacted: January 1, 2016 AB 848 authorizes Department of Health Care Services (DHCS) licensed drug abuse recovery or treatment facility to allow a licensed physician or surgeon or health care practitioner to provide IMS to a resident of the facility under specified conditions New statute Section numbers: Amend Sections 11864.03 & 11834.36 Add to Sections 11834.025 & 11834.026

Definitions Incidental Medical Services – (IMS) IMS are approved services provided at a licensed residential facility by a health care practitioner which addresses medical issues associated with either detoxification or the provision of alcoholism or drug abuse recovery or treatment services to assist in the enhancement of treatment services. IMS does not include provisions of general primary medical care. IMS services must be related to a resident’s process of moving into long-term recovery.

Health Care Practitioner: Health Care Practitioner: A person duly licensed & regulated under Division 2 (commencing with Section 500) of the Business and Professions Code, who is acting within the scope of practice of his or her license or certificate. Medication Assisted Treatment (MAT): MAT includes all drugs approved by the Federal Drug Administration for the treatment of substance use disorders. Reasonable Period of Time: For purposes of Section 11834.025(a)(1), prior to IMS being provided to a resident participant, facilities must obtain the Health Care Practitioner Client Assessment form (DHCS 4026) signed by a health care practitioner for each program participant.

6 Categories of IMS Obtaining Medical Histories Monitoring health status to determine whether the health status warrants transfer of the patient in order to receive urgent or emergent care Testing associated with detoxification from alcohol or drugs Providing alcoholism or drug recovery or treatment services Overseeing patient self-administered medications Treating substance abuse disorders, including detoxification

1. Obtaining Medical Histories A health assessment is required prior to providing IMS. The following elements and must contain the following elements: Initial Screening (DHCS Form # 4026) A Client Heath Questionnaire (DHCS Form #5103). This form is not mandatory. Providers may use a different form as long as it contains the same questions. Currently intoxicated Severity of withdrawal The Medical history shall include: Current Medications Major Medical Illness Injuries Surgeries Hospitalizations Allergies Psychiatric Comorbidity Substance Use Disorders

2. Monitoring health status to determine whether the health status warrants transfer of the patient in order to receive urgent or emergent care Integrated effort of both non-licensed and licensed staff monitoring the resident for appropriate level of care. Health assessment conducted prior to admission to determine if patient is appropriate for care.

Health Assessments may include: Monitoring Activities shall be conducted by: A physical exam Monitoring of patient vital signs Use of standardized rating scales Physicians Health Care Practitioners Non-licensed staff However, they may not perform any monitoring activities which require a medical license

3. Testing associated with detoxification from alcohol or drugs Testing may include: Toxicology for drugs & alcohol Urine drug screening Blood alcohol analysis Confirmatory laboratory analysis

Lab Analysis includes: Analysis for electrolyte disturbances Nutrition deficiencies Organ dysfunction Other Markers impacted by substance use and the withdrawal process The Physician and/or health care practitioner is responsible for reading and making final determination on test results. All test results shall be dated and signed or initialed by the physician and/or health care practitioner.

4. Providing alcoholism or drug abuse recovery or treatment services Laboratory testing may include: Administering and reviewing TB, HIV, Hepatitis & drug and alcohol testing Other screenings that impact provision of treatment services The physician and/or health care practitioner is responsible for reading and making the final determination of test results.

5. Overseeing patient self administered medications A Physician may advise/recommend: Over the counter medication Prescription Medication Prescribe specific medications during detoxification Any medication used to assist the patient through the treatment and recovery process A Physician may also adjust doses of or discontinue medications that may interfere with safe withdrawal or treatment.

6. Treating substance abuse disorders, including detoxification Provision of ongoing medication assisted treatment(MAT) is allowable in a residential setting. Licensed residential providers shall document in their protocols the storage of any scheduled narcotics for MAT. Storage requirements of scheduled medications and/or narcotics must adhere to state and federal guidelines. Protocols and procedures must define how injectable MAT shall be administered, stored and disposed of.

Physician and/or health practitioner staff are allowed to administer injectable or implantable subdermal MAT with the written consent of the patient. All patients prescribed detoxification or maintenance medication shall be seen face-to-face by the physician or health care practitioner prior to the initiation of medication. For patients receiving methadone, licensed residential providers shall collaborate with Narcotic Treatment Programs to coordinate how the patient will receive their medication.

Licensed residential providers are not permitted to allow any form of surgical procedures at a residential facility. Licensed residential providers are not permitted to order or stock bulk prescription medications for utilization during detoxification or treatment nor have them at the facility. Licensed residential providers utilizing relapse prevention medications should ensure staff are trained on the use of the medication.

Application Process Prior to providing IMS, the provider must complete and submit the following: Application Fee Floor Plan Incidental Medical Protocols and Policies/Procedures Health Care Practitioners Acknowledgement (DHCS Form 5256) Copy of the Health Care Practitioner License (License must be valid and in good standing) Fire Clearance - STD 850 (Initial Application only) Current Facility Staffing Data Form (DHCS Form 5050)

Supplemental Application DHCS 5255

Health Care Practitioner Acknowledgement Form-DHCS 5256

IMS Certification Form 4026

Fees Initial Applicants No Fee – Services included in the initial application fee Currently Licensed Providers $1,034 – one time fee provided with Supplemental Application

Regulations and Bulletin Authority Bulletin Authority – Section 11834.025(2) Allows DHCS to implement, interpret or make specific written guidelines or instructions by way of a provider bulletin. Regulations Must be adopted by July 1, 2018

Revocation and Suspension Additional authority added to Section 11834.36 regarding the DHCS’s authority to suspend and/or revoke a residential license. Section 11834.36(a)(6) – “The licensee’s refusal to allow the department entry into the facility to determine compliance with the requirements of this chapter or regulations adopted pursuant to this chapter.” Section 11834.36(a)(7) – “Violation by the licensee of Section 11834.026 or the regulations adopted pursuant to that section.”

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