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  • Writer's pictureKevin Phillips

Comprehensive Program Description

Introduction and Overview


This Program Description supplements the organization’s administrative and clinical policies and procedures and provide additional information relative to Archway Recovery Services, Inc. (ARS) treatment programs. The description has been prepared specifically to conform to national accreditation standards that require such a plan; however, the plan also provides a practical purpose in that it articulates a more detailed description of “treatment-specific” policies and procedures.  Everything contained herein has the same force and effect as formal policy.  


ARS Mission Statement

  1. Our mission is to provide comprehensive Substance Use Disorder treatment and recovery services to anyone who will benefit from the service we provide.

  2. We believe all people deserve to be well and live with dignity. We meet people where they are, we affirm their intrinsic value, and partner with them to enable them to build a more hopeful future. 

  3. We help them step forward strong – into a life of joy and purpose in healthy relationships with others. 


Service Locations

  • Withdrawal Management / Residential Treatment

  • 1095 E. Travis Blvd. Fairfield, CA 94533

  • 2100 Napa Vallejo Highway Building 253 M1M2, Napa, California 94558.

  • Intensive Outpatient and Outpatient Programs: 1234 Travis Blvd. Fairfield, CA 94533


Licensure and National Accreditation    

ARS is licensed by the State of California, Department of Health Care Services .


Legal Compliance

As a matter of policy, ARS will operate in full and complete compliance with all federal and state laws and regulations pertaining to the delivery of substance use treatment services.  ARS has developed a comprehensive corporate compliance program to monitor compliance and to ensure that the organization takes proactive steps to comply with all legal authority and to prevent and detect any illegal or unethical practices. Program details can be found in the organization’s policy on corporate compliance and corporate compliance plan.


Research Projects

ARS’ Residential Treatment Program does not engage in research projects involving patients.  This also extends to the use of two-way mirrors, cameras for patient monitoring purposes (except for common areas in compliance with DHCS standards for health and safety or security reasons), recording devices, or any other technology that could be used to monitor patients, and therefore, pose the potential for a violation of patient confidentiality.    


Program Description and Philosophy


Substance Use Disorder is  a primary, chronic progressive, and fatal disease. Those with SUD suffer not only physically but also mentally, emotionally, and spiritually as well. The devastation of this disorder goes beyond the individual and has far-reaching effects on families, and society. 


Pathological substance use is marked by the physiological and psychological inability to abstain, and impairment in social functioning, emotional and psychological health and stability, behavioral stability, interpersonal relationships and occupational functioning.  Pathological use is often characterized by a myriad of problems or manifestations that include increased incidences of hospitalization and medical problems, arrests and increased involvement with the criminal justice system, loss of friends or negative changes in family and interpersonal relationships, inability to maintain employment, increased financial problems, “acting out” through anti-social behavior.  At a more personal level: loss of self-esteem, self-confidence, and a decreased sense of personal responsibility. 


Our person-centered program applies evidence-based best practices in the treatment of SUD. Our clinical team maintains a standard of treatment consistent with the state of the art as defined by DHCS, the American Society of Addiction Medicine, CARF International, and other industry leaders. We invest in the continuing education and clinical supervision of each member of our clinical team. The clinical team is supported by operational and facilities staff to assure each person receives the clinical support they need to achieve their recovery goals.


The application of evidence-based best practices describes a clinical practice that is planned and systematic. Treatment intervention addresses specific problems identified in collaboration with our patients through a careful and deliberate assessment process. The treatment team is competent within its scope of practice to address the challenges of recovery. The AOD Counselor establishes measurable goals in consultation with the patient that identifies the specific activities and tasks that will advance their personal recovery goals.


Our treatment programs focus on those patients with substance use disorder and those how may also have a cooccurring mental health diagnosis. an addiction to drugs and/or alcohol and helps them break the cycle of the disruptive and self-destructive outcomes of SUD.


ARS programing involves a continuum of care that begins with initial stabilization intended to halt substance use and provide withdrawal management support. It continues with residential treatment intended to help patients practice better emotional regulation and stress management. Emphasis is placed on relapse prevention planning, the develop of social support for long-term recovery, family reunification, and vocational planning. Patients learn about substance use disorder from both a behavioral and neurological perspective  Programing includes motivational enhancement, cognitive behavioral interventions, and trauma informed care through group and individual therapy and psychoeducation. At every level of care. ARS uses evidenced-based curriculum and practice at all levels of care.


Description of Services


ARS programs use an interdisciplinary approach for addressing the personal or social needs of the patient.  Staff applies both in-house resources as well as referral to outside agencies and service providers.  The primary goal is to consistently provide services that respect the cultural diversity of all persons served.  Services provided are intended to: (1) support the recovery and stabilization of patients, (2) enhance their quality of life by restoring and/or improving functioning on several levels, (3) reduce or eliminate symptoms associated with SUD, and (4) support the integration (or reintegration) of patients into their local communities.

ARS identifies “three pillars” of that support long-term recovery. We create programs, activities, and experiences to promote the three pillars in the lives of the people we serve.


Stable Family. A stable family provides a fundamental source of support and encouragement in a person’s life. Family may be represented by one’s biological family of origin. It may also consist of a voluntary association of people who through bonds of affection and mutual support serve as a reliable and sustaining relational foundation. Our program teaches community living skills that helps the people we serve establish a stable family in support of their recovery.


Stable Housing. A stable home allows a person to extend their field of vision beyond the immediate needs of today. When a person knows they will be warm, dry, and well-fed tonight and for the foreseeable future, they experience a reduction in levels of stress, anxiety, and fear. This reduces the potential of relapse. ARS helps the people we serve secure long-term stable housing in support of their recovery.


Stable Employment. Stable employment assures a sustained and sustaining source of income. Our program teaches basic employment skills that enable the people we serve to begin to build a more hopeful financial future for their lives.


Population Served


ARS provides treatment services for males and females, 18 years of age and older.


Levels of Care


The assessment and diagnostic process identifies the appropriate level of care for our patients. We work to identify the least intrusive treatment intervention that is likely to result in the long-term recovery for our patients. The levels of care include:

  • Detoxification and Post-acute Withdrawal Management

  • Long-term Residential Treatment

  • Intensive Outpatient Program

  • Outpatient Program


The levels of care are informed by the patient’s strengths, needs, abilities, and preferences. Level of care placement may also be informed by the expectations, motivations, and sometimes, mandated requirements of different stakeholders related to the patient. ARS provides patient-centered treatment that works to align with diverse goals.

A spouse may demand sobriety as a condition of returning to the home. A court may mandate treatment in lieu of custody. Probation and Parole want to reduce recidivism. A child welfare agency may want to keep children safe and so remove children from a home pending completion of a treatment program and the return a certain number of clean drug tests.

Identified goals also vary among patients. One may be motivated to live a healthier life. Another may be motivated to avoid adverse social consequences such as a job loss or incarceration. Another may be motivated to move out of homelessness.

It is common for recovery goals to change as a person progresses through their recovery and as the transition between levels of care. Consider how the patient experience changes as they progress through treatment and as they transfer between levels of care.


  • Detoxification: I want to stop hurting

  • Post-acute Withdrawal Management: I want to think clearly and sleep through the night.

  • Residential Treatment:

    • I want to satisfy a court mandate.

    • I want to reconcile with my family.

    • I want to live a healthy life.

    • I want to strive for long-term recovery.


  • Intensive Outpatient Program

    • I want to find more healthy ways to manage stress in more healthy ways.

    • I want to avoid relapse.

    • I want to learn about the reasons and patterns of my relapses

    • I want to find a job.

    • I want to find a stable place to live.


  • Outpatient Program

    • I want to become a trustworthy person.

    • I want to balance my family, work, and social life.

    • I want to give back to my community.


Detoxification / Withdrawal Management


Markers indicating a need for this level of care: Active substance use with withdrawal potential


Detoxification services are  provided for patients whose level of physiological and/or psychological dependence upon alcohol and/or other drugs may require prescribed medication for the management of withdrawal, but whose withdrawal signs and symptoms do not require the full resources of a medically monitored inpatient detoxification facility or hospital.

Medications for the management of withdrawal is only provided under the direction of a third-party, licensed medical professional authorized to prescribe drugs under the scope of practice of their professional license.  ARS Staff is trained to provide the patient support through the detoxification/ withdrawal process They are trained on medications used for withdrawal management, the signs and symptoms that require referral to a higher level of care, and in the emotional support of patients in withdrawal. They are certified in first aid and CPR.


ARS will not admit a patient for treatment at this level of care who would not benefit from treatment and/or who presents with symptoms of withdrawal or risk of sever withdrawal that indicates a need for medical monitoring in an inpatient medical setting.

ARS staff monitors each patient receiving detoxification during the first 72 hours following admission. Overnight staff also provide active supervision of patients. Staff closely observe and physically check each patient at least every 30 minutes during the first 72 hours following admission, more often if symptoms indicate a greater risk for seizure. Staff documents observations and physical checks. An observation log is maintained for this purpose.

After 24 hours, close observations and physical checks may be discontinued or reduced based upon a determination by an ARS staff member trained in providing detoxification services who documents how their observation that justifies the decrease in close observation.


Vital signs are  checked every 6 hours (or more if indicated) for the first 72 hours or until the patient has been close observations have been discontinued. A temperature of 100.5F is the standard above which a provider is notified. If other signs and symptoms of fever are present, these will be reported.

Blood pressure of below 90/60 or above 180/110 or significant changes from the patient’s baseline is the standard after which a provider is notified.


A pulse of greater than 110 beats per minute or less than 60 beats per minute is the standard by which a provider is notified. The pulse is taken either by the Radial or Apical method. Pulse is to be counted 15-30 seconds or one full minute if irregular. A normal pulse range is 60-80 beats per minute with an average of 70 beats per minute.


Respiration of less than 12 breaths per minute or greater than 26 breaths per minute or significant changes from the patient’s baseline is the standard by which a provider is notified. 


A patient is ready to transition to long-term residential treatment when a urine analysis test indicates that substances have been cleared by the body the patient demonstrates sufficient cognitive and emotional stability to being programing at the lower level of care.


Residential Treatment


Markers indicating a need for this level of care:

  • The patient demonstrates they are unable to stop use outside a 24 hour, highly structured and supervised environment.

  • The patient demonstrates sufficient motivation to be admitted to treatment.


A patient qualifies for long-term residential treatment after they have safely completed detoxification/withdrawal management, and they are unable to refrain from using substances outside of a structured, 24-hour, supportive environment. Patients at this level of care  receive a physical examination if they had not had one during detoxification. Some may also receive a mental health assessment if ARS suspects an undiagnosed mental health issues.


One myth of SUD treatment is that a person “must be ready” before treatment can work. Studies indicate that SUD treatment can successfully begin at any time. Using the Transtheoretical Model of Change, ARS staff assess patient motivation based on what they say and do. A patient who is in the Precontemplation Stage of change is best served in a residential treatment setting.

Treatment outcomes are conditioned by the motivation of the patient and the quality of their treatment engagement. In residential treatment patients address denial. A successful graduate of the residential treatment program has learned the 12 Denial Patterns, and they are able to identify their own most common denial practices. They have taken time to reflect on the consequences of prior drug use and documented how their substance use has undermined their heath and their relationships. They have learned to nurse a vision of what their life can be like without substance use.

Family life, friends, neighborhood, education, housing, employment, involvement in the justice system, and other social conditions inform the patient’s life-setting. ARS staff must sometimes address suboptimal living conditions the patient has normalized over time. ARS helps the patient develop an understanding of the value of healthy family and relationships, stable work, and safe housing.

For some, living in a residential setting is the first time they have been treated with respect and unconditional regard. Unconditional regard is an attitude of caring, acceptance, affirmation, and validation that others express to someone without reference to their behavior. This is fundamental to shame reduction and raising self-awareness of personal value and potentional for growth. This is of particular importance for patients who grow up with multiple adverse childhood experiences.

Residential treatment also introduces therapeutic community. In a therapeutic community patients begin to practice prosocial, community living skills. Readiness for discharge from the residential setting is in part indicated by patient behavior that demonstrates their ability to continue to participate as contributing member of a therapeutic community in a less structured environment.

Prosocial values that make community living therapeutic include honesty, responsibility-taking, conflict resolution, a healthy work ethic, an openness to other perspectives, and a willingness to learn. These skills take the place of behavioral patterns that reinforce SUD.

Prosocial skills learned and practiced in the residential setting continue to develop in an

intensive outpatient level of care.

Intensive Outpatient Treatment

Markers indicating a need for this level of care:

  • The patient has stopped using substances but risks relapse without daily support.

  • The patient demonstrates that motivation to change is shifting from external to internal locus of control.

  • They patient is taken action to change, and lingering ambivalence may remain.

  • The patient actively seeks supports from others.

  • The patient is willing to be transparent and honest in treatment.

  • The patient participates in treatment on a regular and ongoing basis.


A patient who qualifies for stepping down to intensive outpatient treatment is in the Action Stage of change. They are ready to step down to a lower level of care when their behavior indicates that they have transitioned to Maintenance Stage of change.

At the IOP level of care, a patient receives between 9-19 hours a week of treatment, more if indicated by medical necessity. In the intensive outpatient setting the patient is no longer using substances, but they may remain vulnerable to relapse without support. They have a relapse prevention plan in place, but it is being tested as the patient begins to address the challenge of “living life on life’s terms.” The IOP patient may lapse from time to time. But because they remain in treatment, and because they have developed behaviors associated with honesty, transparency, and an appreciation for the support of a recovery community, it does not result in sustained relapse.

They have resolved any outstanding medical issues, and if indicated, any mental health issues are stabilized. They are living in an environment that supports their recovery and they are participating in a recovery community that genuinely supports their emotional needs. Legal issues are resolved, or they are being resolved with positive outcomes.  They are ready to step down to the outpatient level of care.

Outpatient Program

Markers indicating a need for this level of care:

  • The patient has developed a recovery support community

  • The patient has a realistic relapse prevention plan that they actively use.

  • The patient can identify life-stressors, emotional challenges, and barriers to goals and to process then in a constructive way. 

The outpatient program is up to nine hours a week of treatment. A candidate for the OP level of care has ceased active use. They have developed and enjoy the support of an active recovery community. They have stable employment. They have a safe home and living environment that supports long-term recovery.


An OP patient who has made the recovery journey from detoxification through residential treatment having stepped down to the IOP level of care will have experienced 5-7 months of living without substances. They have been away from substances long enough now to experience life-stressors without turning to a substance to avoid the genuine difficulty and sometimes real pain of daily living.

As an OP patient, the patient is now able to address feelings and develop coping skills that enable them to be in sustained and sustaining relationship with others and to live a prosocial, productive life. They remain in treatment because of the additional support they need to continue their recovery journey. As they gain personal confidence and enjoy the genuine support they have learned to receive from a recovery community, the OP patient may step down to one group a week and an individual counseling session. The work at this level is supportive and will lead soon to a successful discharge from the program.

Recovery Services

A final level of care, Recovery Services, provides for post-treatment support services. This is intended to be an “alumni” service for patients who have completed treatment and who are successfully advancing their recovery goals outside the support of a clinical relationship. Services include occasional group sessions (once or twice a month) and individual counseling sessions as requested by the patient for consultation or additional support. Recovery Services is a relapse prevention measure.


Operating Hours


  • ARS residential treatment program provide service 24 hours a day, 7 days a week for patients with staff always support present. 

  • Intensive Outpatient and Outpatient programing is available Monday through Friday from 8:30 AM to 9:00 PM, with treatment available on Saturday as needed.

  • ARS administrative offices are open Monday through Friday, 8:00 AM to 5:00 PM.


Private Pay Fee for Services


Withdrawal Management                       $400.00/Day

Residential Treatment                             $350.00/Day

Intake and Assessment                          $350.00

Subsequent Assessment                         $250.00

Full Co-Occurring Assessment               $500.00

Outpatient Group Counseling                 $100.00/Hour

Individual Counseling                           $250.00


Payer Sources

ARS may be able to apply various state or county programs for individuals who are underinsured and lack the means to pay. ARS accepts Medi-Cal insurance, and it is in the process of getting into network with private insurance companies.


Program Goals


ARS  has established the following annual goals. These are in addition to the organizational goals developed as part of the organization’s annual strategic planning process:


  1. At least 80% of all patients who successfully complete the continuum of care will maintain a drug-free lifestyle following one year in treatment.

  2. At least 80% of all patients who successfully complete the continuum of care will be employed after one year of treatment or enrolled in educational or vocational pursuits.

  3. At least 80% of all patients  who successfully complete the continuum of care will maintain and demonstrate socially acceptable behavior and be productive members of society after one year in treatment.

  4. At least 80% of all patients who successfully complete the continuum of care participate in at least one support group on a regular basis after treatment.

  5. At least 80% of patients who successfully complete the continuum of care have not experienced any legal problems after treatment


These goals are consistent with the benchmarks measured as part of the organization’s Outcomes Management System.

Mechanisms to Address Special Populations


In most cases, ARS’ staff can accommodate any request for service that falls within the scope of the organization’s capability and scope of practice for its professional staff.  However, if a patient presents for services at ARS and cannot be accommodated for any reason (language barrier, special physical or mobility requirement, etc.), ARS staff will facilitate a referral to another provider to accommodate the patient’s need for services. 


ARS maintains a current listing of community resources to ensure that anyone seeking services at ARS has direct access, or through referral, to a full continuum of behavioral health treatment services. 


Resources, Staffing and Organizational Structure


ARS provides appropriate resources (staff, facilities, equipment, supplies, inventory, etc.) to ensure quality care and continuity of services. The Clinical Manager is responsible for assuring patients receive treatment consistent with ARS standards. A Clinical Supervisor provides direct patient care and supports other AOD Counselors.


The ARS Clinical Director is licensed Clinical Psychologist who is available to Clinical Managers for consultation by phone on a “24/7” basis to provide clinical guidance.  The Clinical Director also provides education and determines program design.


The ARS Medical Director and Associate Medical Director are also available by phone on a “24/7” to address issues related to Medication Assisted Treatment, or other non-emergency medical needs associated with a patient’s SUD treatment. General medical services are provided by third-party providers in the community.


All ARS staff work as an interdisciplinary team within each one’s scope of practice with a goal of providing SUD treatment services that meet the ARS standard. This arrangement provides flexibility to respond directly to any issue of care that may arise in the delivery of treatment services and has proven to be an effective model for service delivery.


All clinical staff employed at ARS have one of the following credentials:

  • Registered AOD Counselor

  • Certified AOD Counselor

  • Licensed Therapist (MFT, CSW, PCC)

  • Registered Associate Therapist

  • Licensed Clinical Psychologist

  • Psychiatric Nurse Practitioner

  • Medical Doctor


The ARS leadership ensures that all members of the ARS Clinical Team are appropriately licensed, credentialed, or registered.  


Admission Criteria and Process            


ARS provides services without regard to age, gender, ethnicity, race, sexual orientation, culture, religion or spiritual belief. A patient must have a substance use disorder to be admitted to this program at all levels of care. This program will only admit patients whose needs it can meet.

Before admission, ARS staff will document that the applicant meets our admission criteria:

  • Patient must be 18 years of age unless they are admitted with a parent(s) as part of a family treatment program.

  • Patient will have at least one diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM V) for Substance Use Disorders or be assessed to be at risk for developing a SUD (for youth under 21).

  • Documentation of social, mental health, physical and/or behavioral problems related to substance use will be included in an assessment.

  • Patient will meet the definition of medical necessity for services based on the ASAM Criteria. If under 18 years old the patient will meet the ASAM adolescent treatment criteria.

  • Patient would benefit from treatment for substance use.

  • Patient has no current medical problems, no diagnosed medical condition, and no condition requiring the immediate attention of a primary care physician or other medical staff.

  • If presenting with psychological and/or behavioral conditions, symptoms must be manageable in the setting.


This program will not admit a patient for treatment who would not benefit from treatment and/or who the Clinical Director deems requires a level of care beyond the scope of our practice.

  • ARS does not provide services to persons under the age of 18.

  • This program will not admit a patient who poses an imminent danger to self, others, and/or property.

  • Presents with an inability to adapt to the program due to a psychological, social, or occupational disability beyond the program staff’s ability to accommodate.

  • Requires excessive support from program staff to satisfy physical or emotional needs due to issues related to non-compliance to treatment, physical conditions, and/or a mental disorder.

  • Presents with a cognitive impairment such that it limits the patient’s ability to engage in programming.

  • Requires an immediate medical evaluation, or higher level of physical or mental health care.

  • Does not voluntarily consent to admission or treatment.


When a patient is found ineligible for treatment they will be informed as to the reason. In accordance with the choice and consent of the patient, the family/support system will be informed, and the referral source will be informed. ARS staff will make referrals for alternative services.


As part of the admission process, a medical history and full assessment is collected and fully documented for each patient receiving services. The assessment includes an interview and discussion with the patient and a review of their medical record and history. Every patient seeking admission to ARS will be oriented to the program in accordance with the organization’s Policy on Patient Orientation.          


Treatment Procedures and Guidelines  


The following procedures and guidelines describe the ARS approach to the delivery of SUD treatment services:




ARS conducts an initial screening and subsequent assessments based on criteria established by the American Society of Addiction Medicine. Additional biopsychosocial assessments may be conducted as indicated. In addition, we complete a Snap Assessment to begin to explore patients strengths, needs, abilities, and preferences. This is followed with a more comprehensive Needs Assessment. These assessments taken together contribute to individualized treatment goals and objectives that are written in quantifiable terms.


Every patient served in a manner that is respectful and considerate of the patient’s (a) age and developmental level, (b) gender identity, (c) sexual orientation, (d) social preferences, (e) cultural background, (f) psychological characteristics, (g) physical condition and (h) spiritual beliefs.  The assessment will also include an opportunity for patients to provide their goals and expectations regarding treatment.


Assessment results are shared with the patient, appropriate staff on a “need to know” basis and other persons as directed by the patient through formal documentation of releases of information. Assessment is commonly shared with the patients insurance company or other payer source.


Assessments are conducted by ARS staff with the appropriate training and professional credential as required by law in the state of California. In addition, information may also be obtained from family members/significant others, friends, peers, and other persons only when permitted and appropriate. 


The assessment process generally includes but is not limited to information related to:

  • Strengths, Needs, Abilities, Preferences

  • Presenting problems

  • Previous treatment history

  • Physical health issues

  • Mental status

  • Current level of functioning

  • Co-occurring disabilities and disorders

  • Current and historical life situation information including age, gender identity, sexual orientation, culture, spiritual beliefs, education history, employment history, military history, legal involvement, family history, relationships, and social determinants of health

  • History of trauma that is experienced and/or witnessed, including abuse, neglect, violence, sexual assault

  • Current and historical use of alcohol, tobacco, and/or other drugs

  • Risk factors for suicide, other self-harm or risk-taking behaviors including violence toward others

  • Level of literacy

  • Need for assistive technology in the provision of services

  • Resultant diagnosis(es), if identified.


The intake/assessment is completed in accordance with specific timelines established by the Department of Health Care Services.


ARS recognizes that many patients who present for treatment are initially unable to participate in treatment planning because of neurological and intellectual impairment due to alcohol or drug use and, that symptom stabilization/mitigation may be necessary before the patient can reasonably be expected to participate as an active member of the treatment team.


The intake/assessment process will result in the preparation of an Intake Summary that is based on the assessment data, which identifies any disorders, co-occurring disorders, co-morbidities, risks for suicide, violence, or other risky behaviors, that is used in the development of the treatment plan. Periodic assessments are conducted as clinically indicated and as determined by the primary counselor.  In writing/preparing Intake Summaries, ARS staff use the following guidelines:


  1. Intake Summaries will not be a mere recapitulation (summary or re-statement) of the information gathered during the assessment process.

  2. Intake Summaries answer fundamental questions about the patient’s anticipated response to treatment services.

  3. All Intake Summaries answer the following questions in narrative form:

  • If a patient has documented co-occurring disorders how will that condition be handled in treatment?

  • Based on the assessment information, can we justify admitting this person to our program based on “medical necessity”?

  • Given what we know about this patient and the information presented during the assessment process, what treatment approach will most likely render an optimal outcome for the patient?

  • What “treatment themes” will most likely present themselves during this person’s treatment experience with ARS?

  • How do we expect this person to respond to treatment services and why?

  • What are the most obvious barriers to this patient’s recovery and success in treatment?

  • What are this patient’s unique skills, needs, abilities and preferences and how can we capitalize on those qualities to optimize the person’s recovery experience?

  • What internal or external support systems does this patient possess and how can be utilize those to optimize the treatment experience for this patient?

  • Based on all the above, what do we believe this patient’s short-term prognosis for recovery/stabilization to be?


The Intake Summary serves as the basis for the development of individualized treatment plans. 


Treatment Planning   


ARS uses a person-centered approach during the formulation of the Treatment Plan. ARS values and encourages the active involvement of patients in the process, including a major role in determining the direction of the treatment plan. To the greatest extent possible, treatment plans reflect that the planning process is “patient-centered”. ARS will defer to Funding Sources/CARF standards regarding the timing of treatment plan completion, treatment plan formats and treatment plan content.


Individualized treatment plans are developed with the active participation of the patient. The Intake Summary provides a starting place for the treatment plan. The treatment plan includes goals and objectives that focus on the initiation of recovery, stabilization/elimination/reduction of symptoms, relapse prevention planning, and the integration and inclusion of the patient into the local community, their family as appropriate, natural support systems, and other necessary supports and services. 


When permitted by the patient and when clinically appropriate, the treatment planning process may involve the patient’s family.  The process will identify those services to be provided by staff as well as any clinical/therapeutic needs beyond those that can be provided by ARS and that will be addressed through referral to other providers/provider organizations. 


The final treatment plan, and more specifically, the goals and objectives outlined on the plan will be communicated the patient in a manner and in terms that are understandable to them.


The initial treatment plan must be developed and implemented within 24 hours of admission in a residential setting and following the first individual appointment with the counselor in an outpatient setting. It includes identified problems including but not limited to such things as:

  • Medical needs

  • Mental health needs

  • Housing needs

  • Needs related to the development of emotional regulation, coping skills, stress management, relational skills, and other behaviors that support long-term recovery

  • Addressing legal issues


Treatment plans include both short- and long-term goals.  Short term goals are realistic, time-limited, and specific in terms of objective and observable behavioral terms. They include a clear statement, preferably from the patient to document the patient’s responsibility regarding each goal. 

Long term goals should also be realistic and within the reach of the patient given their strengths, needs, abilities, and preferences.  Long term goals should be flexible and negotiable so that the patient and treatment team can adjust the goals as progress toward recovery is achieved and should include a statement regarding the patient’s responsibilities regarding accomplishment of those goals.  Finally, long term goals may also include some “deferred” or “referred” problem/issues that may be addressed in the discharge/transition plan. 


Treatment plans are  reviewed regularly, every 7-days in a residential setting, as part of routine clinical supervision and treatment team patient-review sessions and updated as appropriate to ensure continuing relevance to the patient and their needs.  


All treatment plans include the following: 

  • Goals expressed in the words of the patient reflecting that 1) they are fully informed about their treatment, 2) they are appropriate to the patient’s age and culture, and 3) they are based on the patient’s strengths, needs, abilities and preferences.

  • Specific treatment objectives that 1) reflect input from the patient as well as the treatment staff, 2) are reflective of the patient’s age, developmental status, culture and ethnicity, responsive to the patient’s disabilities, clearly understandable to the patient, measurable, achievable, time specific and appropriate to the treatment setting.

  • Frequency of specific treatment interventions.  

  • nformation on, or conditions for, discharge and/or transition to another level of care. 

  • When the patient has a co-occurring disability/disorder, the treatment plan addresses those issues in an integrated manner and will be provided by staff members who are specially trained, experienced and credentialed to provide such services.


Transition, Discharge and Recovery Support Services      

Patients sometimes require services from other providers after discharge or in conjunction with a transition to another level of care.  Such services support advances made in treatment and address clinical problems that are beyond the scope of ARS staff.


Such services may be referred to as “aftercare” or “continuing care”. The term “discharge planning” refers to that planning that anticipates a patient’s discharge or transfer to a lower level of care. It may reference another service provider for continued services. The following guidelines govern discharge/transition planning and the referral to other service providers.

  • Discharge/Transition planning begins at the earliest possible point or treatment following treatment planning.

  • Discharge/transition plan is prepared with each patient leaving the program to ensure continuity of services and identifies the patient’s progress in recovery and individual strengths, needs, abilities and preferences upon discharge/transition.

  • Discharge/transition plans are developed with the active participation of the patient, treatment team members and others as applicable and as authorized by the patient. This may include family members, significant others, legally authorized representatives, referral sources, and persons from other community services.

  • Discharge/transition plans identify the person’s needs for support systems or other services to assist in their recovery.

  • Discharge/transition plans include information on current medications that the patient is taking.

  • Discharge/transition plan include referral source information such as contact name, telephone number, locations, hours and days of service availability.

  • Discharge/transition plans include information on options available if symptoms of relapse occur or if emergency services are necessary.

  • A copy of the discharge/transition plan are provided to the patient and others as advised by the patient.  

  • When the Discharge/transition plan indicates the need for additional services or support, an ARS Care Coordinator will be responsible for follow-up after transition.  The Care Coordinator is responsible for maintaining the continuity and coordination of services, helping the patient determine if additional services are needed and offering to provide, coordinate or refer to needed services as necessary.

  • In the event of an unplanned transition, the Care Coordinator will identify who will follow up with the patient to determine if they need further services and provides or refers to such services when possible.

  • Upon an involuntary discharge, a Care Coordinator conducts follow up within 72 hours to attempt to ensure linkage to appropriate care, if warranted and desired by the patient.


Effective discharge/transition planning requires knowledge of local community.  ARS maintains a community resource directory that lists the appropriate contact information on other providers and provider organizations in the local community.  This directory is updated continuously as new resources are identified by ARS staff. The community resource directory is made available to all ARS staff to ensure that ARS is part of a larger continuum of care in our region.


Crisis/Emergency Services: 

In the event of a medical emergency a patient will be transported by ambulance, to the nearest hospital emergency department (Northbay Hospital in Fairfield, Queen of the Valley Hospital in Napa). The cost of transport is the patient’s responsibility in the unlikely event that it is not covered by Medi-Cal or by the patient’s insurance provider.


Patients remain at the hospital there until they released by medical officials and provided a medical clearance to return to treatment. Upon release patients will call for ARS staff from the hospital f to arrange for transportation for their return. Patients in an ARS residential treatment facility are required to provide documentation of their discharge from the hospital to ARS staff who will include a copy in their patient chart.


In the event of a non-medical emergency in a residential setting, (i.e., a clinical emergency), the on-duty Recovery Technician will contact the on-duty counselor. If this cannot be achieved, they will contact the Residential Services Manager, the Clinical Manager, or the Program Manager.  


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