Behavioral Health Services, Inc.
Subject: Residential SUD Treatment Policy#: 4.11.6.1
Title: Incidental Medical Services – Obtaining Medical Histories
Effective Date: 06/27/24
POLICY:
BHS residential treatment facilities that are licensed by DHCS shall provide IMS – Obtaining Medical Histories with approval of DHCS. DHCS-licensed BHS residential treatment facilities shall have and follow written protocol and procedures in accordance with relevant health and safety codes and other regulatory requirements for the implementation of approved IMS –
Obtaining Medical Histories in their facilities.
PROCEDURES:
Assessment Prior To Admission
• Who performs screening & assessment - the physician or alternate physician shall assess the client in a face to face session to determine whether it is medically appropriate for that client to receive IMS at the premises.
A registered or certified SUD counselor or licensed or license-eligible practitioner of the
healing arts (including LCSW, LMFT, LPCC, RN, or license-eligible practitioner) will also perform the ASAM-based Assessment, which includes biopsychosocial information along six dimensions, and clinical withdrawal scales in a counseling office at the facility or via telehealth
• Where IMS assessment is conducted - in the physical examination room in the facility
• When IMS assessment is conducted – within 24 hours of client’s admission to the facility/program.
• Documentation - The physician or alternate physician who performs the IMS assessment shall review the Health Care Practitioner Client Assessment form (DHCS 4026) for the client within 72 hours of the client’s admission to the facility/program. Completion of the Health Care Practitioner Client Assessment form (DHCS 4026) is included as part of the admission process to the residential program, which also includes the client’s completion of the Client Health Questionnaire and Initial Screening Questions (DHCS 5103) that is reviewed by the physician or other health care practitioner as part of this assessment. Completed, signed and dated forms are maintained in the client’s file within 24 hours of completion.
• Obtaining Medical Histories
• The physician will perform an evaluation of the health status of the client, including current medications and efficacy, major medical illnesses, injuries, surgeries, hospitalizations, allergies, and communicable diseases based on information collected in
the assessment. The medical history includes substance use disorders and psychiatric
comorbidity. Upon initial presentation, the physician, registered or certified SUD counselor, LPHA or LEPHA will determine whether the client is currently intoxicated, the type and severity of the withdrawal symptoms and information regarding past withdrawal and/or withdrawal treatment episodes.
Referral for individuals not appropriate for IMS
• Those individuals who are determined at this point to not be appropriate to receive IMS at the facility shall be referred to an appropriate provider.
• Emergency services will be contacted for conditions requiring immediate medical
treatment and transported to nearest medical facility.
Documentation of referrals shall be included in the client’s file within 24 hours.
