The facility must maintain a written policy and procedures manual which includes the following elements:

(1) 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.
(2) A written program description which must be available to staff, clients, and members of the public. The description must include but need not be limited to the following:
(a) A comprehensive statement of the philosophy that guides the program services, structure, and practices,
(b) Services offered by the facility, availability of staff (including medical) to provide services, and hours of operation,
(c) Characteristics of the person(s) to be served,
(d) Process of referral into the program,
(e) Admission criteria,
(f) Re-admission exclusion criteria,
(g) Facility rules for clients
(h) Referral mechanisms for services outside the facility (both medical and non-medical)
(i) Emergency and non-emergency transportation of clients, and
(j) Discharge criteria.
(3) Policies and procedures which address the methods for managing disruptive behavior
(4) If restrictive procedures are used to manage disruptive behaviors, written policies and procedures must govern their use and must minimally ensure all of the following:
(a) Restrictive procedures 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.
(b) The parents or guardian must have given written consent to any restrictive measures taken by the treatment staff, unless the child is over 16 years of age and has signed him/herself into the program. In this case, the child may give such written consent.
(c) The restrictive procedure(s) must be documented in the Individual Program Plan, be justified as part of the plan, and meet all requirements that govern the development and review of the plan.
(d) Only mental health professionals or mental health personnel may use restrictive procedures and must be adequately trained in their use.
(e) The adaptive or desirable behavior should be taught to the client in conjunction with the implementation of the restrictive procedures.
(5) A policy which states physical holding must be implemented in such a way as to minimize any physical harm to the client and may only be used when the client poses an immediate threat under the following conditions:
(a) The client poses an immediate danger to self or others, and/or
(b) To prevent the client from causing substantial property damage.


Tenn. Comp. R. & Regs. 0940-05-30-.01
Original rule filed January 11, 1996; effective March 26, 1996.

Authority: T.C.A. ยงยง 4-4-103, 33-2-504 and 33-1-205(b)(5).

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

No prior version found.