Tenn. Comp. R. & Regs. 0940-05-43-.03

Current through December 18, 2024

Section 0940-05-43-.03 - 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 its aftercare services;

(c) Exclusion criteria for persons not appropriate for the facility's services;

(d) 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;

(e) A policy ensuring that employees and volunteers practice infection control procedures and standard precautions that will protect the service recipient from infectious diseases;

(f) 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;

(g) Drug testing procedures, if any, used by the facility;

(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 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

5. The adaptive or desirable behavior must be taught to the service recipient in conjunction with the implementation of the restrictive procedures.

(i) A policy which states physical holding must 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 substantial property damage.

(j) Procedures to ensure that the facility, either directly or through arrangements with other public or private nonprofit entities, will make available tuberculosis (TB) services in accordance with current TB Guidelines for Alcohol and Drug Treatment Facilities (TB Guidelines), established by the Department of Health TB Elimination Program and the Department of Mental Health and Developmental Disabilities 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 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;

Tenn. Comp. R. & Regs. 0940-05-43-.03

Original rule filed April 27, 2000; effective July 11, 2000. Amendment filed March 1, 2007; effective May 15, 2007. On May 15, 2008, rule was transferred from 1200-8-18 per Executive Order 44 (February 23, 2007). Repeal and new rule filed July 31, 2008; effective October 14, 2008.

Authority: T.C.A. §§ 4-4-103, 4-5-202, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, 33-2-404 and Executive Order 44 (February 23, 2007).