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RULE §448.802Admission Authorization and Consent to Treatment

(a) A QCC shall authorize each admission in writing and specify the level of care to be provided. If the screening counselor or intern is not qualified to authorize admission, the QCC shall review the results of the screening with the applicant, directly or indirectly, before authorizing admission. The authorization shall be documented in the client record and shall contain sufficient documentation to support the diagnosis and the placement decision.

(b) The facility shall obtain written authorization from the consenter before providing any treatment or medication. The consent form shall be dated and signed by the client, the consenter, and the staff person providing the information, and shall document that the client and consenter have received and understood the following information:

  (1) the specific condition to be treated;

  (2) the recommended course of treatment;

  (3) the expected benefits of treatment;

  (4) the probable health and mental health consequences of not consenting;

  (5) the side effects and risks associated with the treatment;

  (6) any generally accepted alternatives and whether an alternative might be appropriate;

  (7) the qualifications of the staff that will provide the treatment;

  (8) the name of the primary counselor;

  (9) the client grievance procedure;

  (10) the Client Bill of Rights as specified in §148.701 of this title;

  (11) the program rules, including rules about visits, telephone calls, mail, and gifts, as applicable;

  (12) violations that can lead to disciplinary action or discharge;

  (13) any consequences or searches used to enforce program rules;

  (14) the estimated daily charges, including an explanation of any services that may be billed separately to a third party or to the client, based on an evaluation of the client's financial resources and insurance benefits;

  (15) the facility's services and treatment process; and

  (16) opportunities for family to be involved in treatment.

(c) This information shall be explained to the client and consenter in simple, non-technical terms. If an emergency or the client's physical or mental condition prevents the explanation from being given or understood by the client within 24 hours, staff shall document the circumstances in the client record and present the explanation as soon as possible. Documentation of the explanation shall be dated and signed by the client, the consenter, and the staff person providing the explanation.

(d) The client record shall include a copy of the Client Bill of Rights dated and signed by the client and consenter.

(e) If possible, all information shall be provided in the consenter's primary language.

(f) If an individual is not admitted, the program shall refer and assist the applicant to obtain appropriate services.

(g) When an applicant is screened and determined to be eligible for services but denied admission, the facility shall maintain documentation signed by the examining QCC which includes the reason for the denial and all referrals made.

Source Note: The provisions of this §448.802 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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