Office of Alcoholism and Substance Abuse Services (OASAS) Publishes "Auto-Waiver" For Certain Providers To Reduce Admissions and Discharge Documentation Requirements When Transferring Patients

Effective May 22, 2017, OASAS providers that operate multiple bedded programs can obtain a waiver for admission/discharge documentation requirements when transferring patients between different levels of care. The providers covered under this waiver include those that fall under Title 14 of the New York Regulations, Parts 816 (Chemical Dependence Withdrawal and Stabilization Services); 818 (Chemical Dependence Inpatient Rehabilitation Services); 819 (Chemical Dependence Residential Services); and 820 (Residential Services). According to OASAS, the purpose of this waiver is to reduce documentation for patient admissions and discharges "to facilitate intra-agency clinically justified patient transfers between modalities" of care.

The "auto-waiver" sets out requirements for the transferring/discharging program and the receiving/admitting program. After a patient has been admitted and treated in compliance with the appropriate documentation and regulatory requirements, and it appears based on this treatment that the patient should be transferred to a higher or lower level of care, the waiver applies so long as the provider follows these rules:

• A transferring/discharging program must:

(1) "[P]rovide a notation in the patient's clinical record indicating the patient has been 'discharged' to another level of care and the treatment/recovery plan has been updated; [and] submit the appropriate PAS form to OASAS for discharge;" and

(2) "[E]nsure that updated patient documentation follows the patient to the new program on the same date (if EMR, then in real time)."

• The receiving/admitting program must:

(1) "[P]rovide a notation in the patient's record indicating the patient has been 'admitted' with an up-to-date treatment/recovery plan and then update the pyscho social assessment with additional clinical information needed to comply with regulations of the receiving/admitting program and ensure quality clinical care; [and] submit the appropriate PAS form to OASAS for admission;" and

(2) "[Prepare] [a] full discharge summary and discharge documentation pursuant to regulatory requirements . . . when the patient leaves treatment . . . ; [and] submit the appropriate PAS form to OASAS for discharge."

According to OASAS these regulatory amendments are forthcoming and it is recommended that for the purpose of audits, a copy of this letter should be included in any patient chart that used this waiver as a means of admission/discharge documentation. The OASAS letter can be found here: Letter from Counsel re. admission/discharge documentation by providers with multiple bedded programs.