Tenn. Comp. R. & Regs. 0940-05-41-.03 - POLICIES AND PROCEDURES

(1) The facility must maintain a written policy and procedure manual which includes the following:
(a) The intake and assessment process;
(b) A description of its aftercare service;
(c) A policy ensuring that employees and volunteers practice standard precautions as specified by the Centers for Disease Control (CDC) to prevent transmission of infections, HIV, and communicable diseases;
(d) Guidelines and techniques for volunteers and employees to monitor, control and report facility infections;
(e) A quality assurance procedure which assesses the quality of care at the facility. This procedure must ensure treatment has been delivered according to acceptable clinical practice;
(f) Drug testing procedures if used by the facility;
(g) Exclusion criteria for service recipients not appropriate for the facility's services;
(h) Policy and procedures which address the methods for managing disruptive behavior. If restrictive procedures are used to manage disruptive behaviors, these policies and procedures must comply with Chapter 0940-3-9U se of Isolation, Mechanical Restraint, and Physical Holding Restraint in Mental Health Residential Treatment Facilities;
(i) A policy that identifies efforts to reduce the use of isolation and restraint;
(j) 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 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 the 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.
(k) A policy and procedure that establishes when employment is appropriate and requires all service recipients be gainfully employed, actively pursuing employment, or participating in vocation education/rehabilitation;
(l) A weekly schedule of all program services and service recipient activities for each day specifying the type of service/activities and scheduled times;
(m) A requirement that the facility provide to the service recipient, upon admission, a written statement outlining in simple, non-technical language all rights of service recipients under Title 33. These rights must include provisions to prohibit:
1. Denial to the service recipient of adequate food, treatment/rehabilitation activities, religious activities, mail or other contacts with family as punishment; and
2. Confinement of the service recipient to his/her room or other place of isolation as punishment. This does not preclude requesting service recipients to remove themselves from potentially harmful situations in order to regain self-control.


Tenn. Comp. R. & Regs. 0940-05-41-.03
Original rule filed July 27, 2000; effective October 10, 2000. Amendment filed March 1, 2007; effective May 15, 2007. Per Executive Order 44 (February 23, 2007), rule was transferred from 1200-8-22 on May 15, 2008. Repeal and new rule filed July 31, 2008; effective October 14, 2008.

Authority: T.C.A. ยงยง 4-4-103, 4-5-202, 4-5-204, 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).

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