Policies And Procedures

(1) The facility must maintain a written policy and procedure manual which includes the following: (a) The intake and assessment process; (b) A description of its 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) A policy ensuring that employees and volunteers practice standard precautions for infection control as specified by the Centers for Disease Control; (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 clinical practice; (f) Drug testing procedures if used by the facility; (g) Eligibility criteria including exclusion criteria for service recipients not appropriate for the facility’s services; (h) Policies and procedures which address the methods for managing disruptive behavior. If restrictive procedures are used to manage disruptive behaviors, these policies and procedures must comply with Chapter 0940-3-9 Use of Isolation, Mechanical Restraint, and Physical Holding Restraint in Mental Health Residential Treatment Facilities; (i) A procedure for notifying the Office of Licensure upon the eighteenth birthday of the service recipient with a plan that targets discharge within ninety (90) days. If the treatment extends beyond ninety (90) days past the service recipient’s eighteenth birthday, a waiver must be sought from the Department; (j) 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; 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; and (k) 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 MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG CHAPTER 0940-05-46 RESIDENTIAL TREATMENT FACILITIES FOR CHILDREN AND YOUTH 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; 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; 3. Providing for or referring the service recipients infected by TB for appropriate medical evaluation and treatment; and 4. Conducting case management activities to ensure that service recipients receive such services.