Policies And Procedures

(1) The facility must maintain a written policy and procedures manual which includes the following: (a) Intake and assessment process; (b) A description of the aftercare service; (c) Requirements that each employee or volunteer comply with procedures for detection, prevention, and reporting of communicable diseases according to procedures of the Tennessee Department of Health; (d) Policies and procedures to ensure employees and volunteers practice standard precautions for infection control, as defined by the Centers for Disease Control (CDC); (e) A quality assurance procedure which assesses the quality of care at the facility. This procedure must ensure appropriate treatment has been delivered according to acceptable clinical practice; (f) Drug testing procedures if used by the facility; (g) Exclusion and inclusion criteria for service recipients seeking the facility’s services; (h) Written admission protocols to screen for potentially aggressive or violent service recipients; MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND CHAPTER 0940-05-44 DRUG RESIDENTIAL DETOXIFICATION TREATMENT FACILITIES (i) Policies and procedures which address the methods for managing disruptive behavior including techniques to de-escalate anger and aggression; (j) If restrictive procedures are used to manage disruptive behaviors, the written policies and procedures governing this use must comply with the Tennessee Department of Mental Health and Substance Abuse Services rules in Chapter 0940-03-09 Use of Isolation, Mechanical Restraint, and Physical Holding Restraint in Mental Health Residential Treatment Facilities; (k) For facilities providing clinically managed detoxification, procedures to ensure an assessment on admission by trained staff using a physician-approved protocol to determine if detoxification can safely occur in a clinically managed setting; (l) For facilities providing clinically managed detoxification with self-administered detoxification medications, procedures for a physical examination by a physician, physician assistant or nurse practitioner as part of the initial assessment; (m) For facilities providing medically monitored detoxification, procedures to ensure an assessment by a licensed nurse using a physician-approved protocol, or a physician, physician assistant or nurse practitioner, to determine whether services can be safely provided in a medically monitored residential treatment setting; (n) For facilities providing medically monitored detoxification, procedures for a physical examination within twenty-four (24) hours of admission by a physician, physician assistant or nurse practitioner; (o) Procedures for referring service recipients whose needs cannot be met to an appropriate level of care at another facility or an acute care hospital; (p) Program admission criteria related to the results of the physical assessment; (q) Physician-approved protocols for service recipient observation, supervision, and determination of appropriate level of care; (r) Procedures and criteria for more extensive medical intervention and/or transfer to a more intensive service including an acute care hospital if a service recipient has, at a minimum, any of the following conditions: 1. A history of severe withdrawal, multiple withdrawals, delirium tremens, or seizures; 2. Sustained extremes in heart rate; 3. Cardiac arrhythmia; and/or 4. Unstable medical conditions including hypertension, diabetes, or pregnancy; (s) Procedures to ensure that the facility, either directly or through arrangements with other public or private non-profit entities, will make available tuberculosis (TB) services in accordance with current Tennessee TB Guidelines for Alcohol and Drug Treatment Facilities (TB Guidelines), established by the Department of Health TB Elimination Program and the Tennessee Department of Mental Health and Substance Abuse Services Division of Alcohol and Drug Abuse, including: 1. Counseling the service recipients about TB; MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND CHAPTER 0940-05-44 DRUG RESIDENTIAL DETOXIFICATION TREATMENT FACILITIES 2. Screening all service recipients for TB and, if applicable, testing service recipients at high risk for TB to determine whether the service recipients have been infected with TB; and 3. Providing for or referring the service recipients infected by TB for appropriate medical evaluation, treatment, and case management activities; (t) Procedures to ensure that service recipients under age eighteen (18) will be treated separately from service recipients eighteen (18) years of age or older; (u) Procedures to ensure implementation of physician-approved protocols for service recipient observation and supervision and documentation of any concerns indicated by the protocol that need to be reviewed by a physician; and (v) A requirement that the facility provide to the service recipient, upon admission, a written statement outlining in simple, non-technical language all rights of service recipients under Title 33. These rights must include provisions to prohibit: 1. Denial to the service recipient of adequate food, treatment/rehabilitation activities, religious activities, mail or other contacts with family as punishment; and 2. Confinement of the service recipient to his/her room or other place of isolation as punishment. This does not preclude requesting service recipients to remove themselves from potentially harmful situations in order to regain self-control.