Job Description
Position Summary: Responsible for providing clinical counseling services to Morse Clinic patients and providing addiction treatment and rehabilitation services. Responsible for providing a range of cognitive, behavioral, and other substance use focused and co-occurring therapies, reflecting a variety of medically necessary evidenced based, individualized, person centered care. The LCAS provides clinical program supervision to the OTP clinical staff. All clinical services must be identified and meet medical necessity criteria based on the clinical assessment and documented in the patient's individualized person centered plan. Clinical services may be provided on-site or through telehealth based on patients needs. Essential Duties and Responsibilities: (this includes the following and other duties as assigned.)Provides individual and group counseling to patients assigned to caseload. Documents all time spent with patients and all calls related to patients in Electronic health record - Methasoft. Maintains accurate service notes and documentation for all interventions provided. All case notes are completed and signed within 24 hours.Function as a liaison with other community based agencies and law enforcement agencies to ensure continuity of treatment (referrals) and compliance to legal obligations.Completes screening for new patients, as needed.Completes individual comprehensive assessment and other required admission paperwork for new patients. This includes all other consents, ROIs, transition plan, PCP/Crisis Plan, NCTOPPS, and GPRA, as needed. The counselor is responsible for the accuracy and completion (all blanks filled) of the assessment process.Annual CCA and other documentation is completed in a timely fashion.Developing individualized PCP and its ongoing revisions in coordination with the patient and ensures its implementation. A Person Centered Plan (PCP) for the new patient is developed and signed on the day of patients admission. This PCP is completed with the patients input and consultation; verified by the patients signature on the treatment plan. PCPs will comply with the documentation standards for Medicaid treatment for all patients.Ongoing treatment plans/crisis plans are required on all patients and will reflect current problems/goals. All goals on the Treatment Plans will be expressed in the words of the person served. PCP Revisions will be completed and signed on the day of completion. Medication types and dosages will be updated with each review. Drugs screens and treatment compliance will be discussed, as well. Completed documentation will be uploaded to Methasoft.Provide crisis interventions when clinically appropriate; Orientation of all new patients will be completed within 30 days of admission.Work with the lab and medical staff in reviewing drug screen samples for monthly urinalysis. Will review results in the patients electronic record and discuss in counseling sessions as needed.Active involvement in Diversion Control through execution of random bottle recalls.Provide necessary forms to the Medical provider, properly and accurately completed, when the patient has special requests for take-out medications, dose changes, phase changes, guest dosing and medication changes. Ensures that patient confidentiality is protected by properly completing release of information to ALL outside referrals and contacts (i.e. Medical coordination, information from other facilities). All information shared via ROI will be documented in Methasoft in compliance with HIPAA/CFR 42 part 2 and documentation rules.Follow-up phone calls to patients after missed appointments and dosing. Follow up phone calls to patients after discharge.The counselor is responsible for all assigned patients files; these files are to be kept in compliance with DHHS regulations as well as the Policy and Procedure Manual of Morse Clinics. This includes protection of the file from any and all unauthorized access. Computers will remain locked and secured in a locked office at all times.A patient is discharged from the program after 30 days from the last scheduled appointment and/or dispensing of medication. A discharge summary is completed in Document manager and in Methasoft. Also, a patient should be discharged from NCTOPPS, GPRA, and MCO as needed and documented in Methasoft. Attends all treatment teams, supervision and staff meetings.Provides substance use, health and community services education; Provides education and public information services to the general public and the professional community regarding opioid treatment programs.Completes Referrals and coordination of care as well as referral follow-up/tracking. Provides linkage and referrals for recovery services and supports, community resources and benefits and services;Provides coordination and consultation with medical, clinical, familial and ancillary relevant parties with patient consents. Ensures linkage to the most clinically appropriate and effective services along with arranging psychological and psychiatric evaluations; Follows the Ethical guidelines of their certification or licensing body in all aspects of their work.Participates in the Continuing Quality Improvement- Post Intake audits monthly and Peer Reviews Quarterly.Answers Crisis Phone as scheduled.Follows all Morse Clinic Policy and Procedures and any updates or improvements.Maintains HIPAA and CFR 42 Part 2 compliance in all interactions with or for patients.Ongoing Relias training completed in a timely fashion. CPI training annual.
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Chatham Recovery, PLLC/Morse Clinic of Asheboro
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