Policies And Procedures

(1) The facility must maintain a written policy and procedure manual which includes the following: (a) A description of the intake, assessment, and treatment 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) Program admission criteria related to the results of the physical assessment; (i) Written admission protocols to screen for potentially aggressive or violent service recipients; (j) Policies and procedures which address the methods for managing disruptive behavior including techniques to deescalate anger and aggression; (k) If restrictive procedures are used to manage disruptive behaviors, policies and procedures that govern their use and minimally ensure the following: 1. Any restrictive procedure must be used by the facility only after all less-restrictive alternatives for dealing with the problem behavior have been systematically tried or considered and have been determined to be inappropriate or ineffective; 2. The service recipient must have given written consent to any restrictive measures taken with him/her by the staff; 3. The restrictive procedure(s) must be documented in the individual program plan, be justifiable as part of the plan, and meet all requirements that govern the development and review of the plan; 4. Only qualified personnel may use restrictive procedures and must be adequately trained in their use; and MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND CHAPTER 0940-05-47 DRUG OUTPATIENT DETOXIFICATION TREATMENT FACILITIES 5. The adaptive or desirable behavior must be taught to the service recipient in conjunction with the implementation of the restrictive procedures. (l) If physical holding is used, a policy that requires it to be implemented in such a way as to minimize any physical harm to the service recipient and may only be used when the service recipient poses an immediate threat under the following conditions: 1. The service recipient poses an immediate danger to self or others; and/or 2. To prevent the service recipient from causing significant property damage. (m) Procedures for a physical examination by a physician, physician assistant or nurse practitioner as part of the initial assessment to determine the safety of providing detoxification services in an outpatient setting in accordance with Rule 0940-05-47-.05 Service Recipient Assessment Requirements. (n) Physician-approved protocols for service recipient observation, supervision, determination of appropriate level of care, and documentation of any concerns indicated by the protocol that need to be reviewed by a physician. (o) 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; 4. Sustained extremes in blood pressure; 5. Unstable medical conditions including hypertension, diabetes or pregnancy. (p) Procedures to ensure that service recipients under age eighteen (18) will be treated separately from service recipients eighteen (18) years of age or older; and (q) 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 Services, 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; and 3. Providing for or referring the service recipients infected by TB for appropriate medical evaluation, treatment, and case management activities.