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.
Notes
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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