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RULE §448.902Requirements Applicable to Detoxification Services

(a) A facility providing detoxification services shall ensure every individual admitted to a detoxification program meets the DSM criteria for substance intoxication or withdrawal.

(b) All detoxification programs shall ensure continuous access to emergency medical care.

(c) The program shall have a medical director who is a licensed physician. The medical director shall be responsible for admission, diagnosis, medication management, and client care.

(d) The medical director or his/her designee (physician assistant, or nurse practitioner) shall approve all medical policies, procedures, guidelines, tools, and the medical content of all forms, which shall include:

  (1) screening instruments and procedures;

  (2) protocol or standing orders for each major drug category of abusable drugs (opiates, alcohol and other sedative-hypnotic/anxiolytics, inhalants, stimulants, hallucinogens) that are consistent with guidelines published by nationally recognized organizations (e.g., Substance Abuse and Mental Health Services Administration, American Society of Addiction Medicine, American Academy of Addiction Psychology);

  (3) procedures to deal with medical emergencies;

  (4) medication and monitoring procedures for pregnant women that address effects of detoxification and medications used on the fetus; and

  (5) special consent forms for pregnant women identifying risks inherent to mother and fetus.

(e) The medical director or his/her designee (physician assistant, nurse practitioner) shall authorize all admissions, conduct a face-to-face examination, to include both a history and physical examination of each applicant for services to establish the Axis I diagnosis, assess level of intoxication or withdrawal potential, and determine the need for treatment and the type of treatment to be provided to reach a placement decision.

  (1) The examination shall identify potential physical and mental health problems and/or diagnoses that warrant further assessment.

  (2) The authorization and examination shall be documented in the client record and shall contain sufficient documentation to support the diagnoses and the placement decision. If the physician determines an admission was not appropriate, the client shall be transferred to an appropriate service provider.

  (3) The face-to-face examination (history and physical examination) and signed orders of admission shall occur within 24 hours of admission.

  (4) The program may accept an examination completed during the 24 hours preceding admission if it is approved by the program's medical director or designee and includes the elements of paragraphs (1) and (2) of this subsection. The program may not require a client to obtain a history and physical as a condition of admission.

  (5) Detoxification programs shall have a licensed vocational nurse or registered nurse on duty for at least eight hours every day and a physician or designee on call 24 hours a day.

  (6) Detoxification programs shall ensure that detoxification services are accessible at least 16 hours per day, seven days per week.

(f) Providers shall develop and implement a mechanism to ensure that all direct care staff in detoxification programs have the knowledge, skills, abilities to provide detoxification services, as they relate to the individual's job duties. Providers must be able to demonstrate through documented training, credentials and/or experience that all direct care staff are proficient in areas pertaining to detoxification, including but not limited to areas regarding:

  (1) signs of withdrawal;

  (2) observation and monitoring procedures;

  (3) pregnancy-related complications (if the program admits women);

  (4) complications requiring transfer;

  (5) appropriate interventions; and

  (6) frequently used medications including purpose, precautions, and side effects.

(g) Residential and ambulatory (outpatient) detoxification programs shall provide monitoring to manage the client's physical withdrawal symptoms. Monitoring shall be conducted at a frequency consistent with the degree of severity of the client's withdrawal symptoms, the drug(s) from which the client is withdrawing, and/or the level of intoxication of the client. This information will be documented in the client's record and reflected in the client's orders.

  (1) Monitoring shall include:

    (A) changes in mental status;

    (B) vital signs; and

    (C) response of the client's symptoms to the prescribed detoxification medications

  (2) Use of instruments such as the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) for alcohol and sedative hypnotic withdrawal and the "clinician's assessment" in the Behavioral Health Integrated Provider System (BHIPS) is recommended.

  (3) More intensive monitoring is required for clients with a history of severe withdrawal symptoms (e.g. a history of hallucinosis, delirium tremors, seizures, uncontrolled vomiting/dehydration, psychosis, inability to tolerate withdrawal symptoms, self harming attempts), or the presence of current severe withdrawal symptoms and/or co-occurring medical and psychiatric disorders.

  (4) At a minimum, monitoring should be done every four hours in residential detoxification programs for the first 72 hours and as ordered by the medical director or designee thereafter, dependent on the client's signs and symptoms.

  (5) Medication should be available to manage withdrawal/intoxication from all classes of abusable drugs.

  (6) Medication "regimens", "protocols" or standing orders can be used, but detoxification should be tailored to each client's need based on vital signs and symptom severity (objective and subjective) and noted in the client's record.

  (7) Ambulatory detoxification should have clear documentation by the physician or designee that the client's symptoms are or are expected to be of a severity that necessitates a minimum of once a day monitoring.

(h) In addition to the management of withdrawal and intoxicated states, detoxification programs shall provide services, including counseling, which are designed to:

  (1) assess the client's readiness for change;

  (2) offer general and individualized information on substance abuse and dependency;

  (3) enhance client motivation;

  (4) engage the client in treatment; and

  (5) include a detoxification plan that contains the goals of successful and safe detoxification as well as transfer to another intensity of treatment. At least one daily individual session by a registered nurse, QCC or counselor intern with the client will be conducted.

(i) Ambulatory detoxification shall not be a stand alone service and services shall be provided in conjunction with outpatient treatment services. When treatment services are not available in conjunction with ambulatory detoxification services, the ambulatory detoxification program shall arrange for them.

(j) Bunk beds shall not be used in residential detoxification programs.

(k) In residential programs, direct care staff shall be on duty where the clients are located 24 hours a day.

  (1) During day and evening hours, at least two staff shall be on duty for the first 12 clients, with one more staff on duty for each additional one to 16 clients.

  (2) At night, at least one staff member with detoxification training shall be on duty for the first 12 clients with one more staff on duty for each additional one to 16 clients.

(l) Clients who are not in withdrawal but meet the DSM criteria for substance dependence may be admitted to detoxification services for 72 hours for crisis stabilization.

(m) Crisis stabilization is appropriate for clients who have diagnosed conditions that result in current emotional or cognitive impairment in clients such that they would not be able to participate in a structured and rigorous schedule of formal chemical dependency treatment.

  (1) The specific client signs and symptoms that meet the DSM or other medical criteria for the disorder must be documented in the client record.

  (2) Documentation must also include what symptoms are precluding the client from participating in treatment and the manner in which they are to be resolved.

Source Note: The provisions of this §448.902 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842

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