Provision of Services: A physician or other qualified and licensed professional must supervise Substance Abuse Outpatient Services. Professionals must have a license, be in good standing in the State of Texas, and have at least 1,000 hours of documented experience treating substance-related disorders. Qualified and licensed professionals include:

• Licensed Chemical Dependency Counselor (LCDC)
• Licensed Professional Counselor (LPC)
• Licensed Master Social Worker (LMSW)
• Licensed Marriage and Family Therapist (LMFT)
• Licensed psychologist
• Licensed physician
• Licensed physician assistant
• Certified Addictions Registered Nurse (CARN)
• Advanced Practice Registered Nurse recognized by the Board of Nurse Examiners as a Clinical Nurse Specialist (APRN-CNS) or a Psychiatric-Mental Health Advanced Practice Nurse (APN-P/MH)

Services include and are limited to:

• Pre-treatment and recovery readiness programs
• Harm reduction
• Mental health counseling associated with substance use disorder
• Medication-assisted therapy
• Neuropsychiatric pharmaceuticals
• Relapse prevention
• Acupuncture

A licensed acupuncture provider must provide acupuncture services. Agencies providing acupuncture services must have a referral from the client’s HIV medical provider and cannot use acupuncture as the primary treatment modality.

1. Percentage of clients with documentation a physician or qualified licensed professional provided or supervised services.
    
2. Percentage of clients with documentation that HRSA and DSHS allow all services provided under the Ryan White Part-B and State Services program. 

Comprehensive Psychosocial Assessment: An LCDC or other qualified professional must complete a comprehensive psychosocial assessment for all clients.

Professional staff must complete the comprehensive assessment no later than the third counseling session and ensure that the assessment includes the following, as applicable:

• Presenting problems
• Alcohol and other substance use
• Psychiatric and chemical dependency treatment
• Medical history and current health status
• Client strengths and challenges, coping mechanisms, and self-help strategies
• Psychosocial history, which may include:
  • Living situation
  • Social support and family relationships
  • Education and employment history, including military service
  • Sexual and relationship history and status
  • Physical, emotional, or sexual abuse history
  • Domestic violence assessment
  • Trauma assessment
  • Legal history
  • Leisure and recreational activities

Staff may use approved assessment tools such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) for substance use and sexual history, and the Mini-Mental State Examination (MMSE) for cognitive assessment. Staff may use other industry-recognized assessment tools if approved by the provider agency.
 

3. Percentage of clients with documentation of an initial comprehensive assessment completed by the third counseling session.

Treatment Plan: Staff must complete a treatment plan specific to individual client needs within 30 calendar days of completing a comprehensive psychosocial assessment.

Treatment planning is a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies and modalities for achieving them.

The treatment plan must include documentation of the following:

• Goals and objectives of treatment
• Treatment start date and projected end date
• Quantity, frequency, and modality of treatment
• Regular monitoring and assessment of client progress
• Any recommendations for follow-up
• Signature of staff providing services or the staff’s supervisor

Staff will offer appropriate referrals to clients for support services as applicable to meet goals.

4. Percentage of clients with documentation of a treatment plan completed within 30 calendar days of the completed comprehensive assessment.
    
5. Percentage of clients with documentation that staff reviewed or modified treatment plans at least once, midway through the number of agreed-upon sessions.

Progress Notes: Staff must provide services according to the individual's treatment plan and document services in the client's primary record. For each professional counseling session, the counselor should document a progress note that includes:

• Client name
• Session date
• Clinical observations
• Focus of the session
• Interventions
• Assessment
• Duration of session
• Newly identified issues or goals
• Client’s responses to interventions and referrals
• HIV medication adherence
• Substance use treatment adherence
• Documentation of missed visits with attempts to reschedule as applicable

6. Percentage of clients with documented progress notes for each counseling session that the client attended, or documentation of missed visits and attempts to reschedule, as applicable.

Discharge Summary: Agencies may discontinue services when the client:

• Reaches goals and objectives
• Demonstrates ongoing non-adherence to the treatment plan
• Has missed three consecutive appointments in a six- month period
• Self-terminates services
• Demonstrates unacceptable behavior
• Is deceased

When an agency discharges a client, staff will document a discharge summary in the client chart that includes:

• Circumstances of discharge
• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during counseling
• Referral to a case manager or primary care provider, as appropriate
• Signature of provider

Staff will complete discharge planning in collaboration with the client when possible. Providers will attempt to link clients who leave care with appropriate services to meet their needs.

7. Percentage of clients with documentation of discharge summary, as applicable.