Substance Abuse Services (Residential)

Service Standard

Substance Abuse Services (Residential) Service Standard print version

Subcategories	Service Units
Substance Abuse Services (Residential) - Detox	Per day
Substance Abuse Services (Residential) - Treatment	Per day

Health Resources & Services Administration (HRSA) Description:

Substance Abuse Services (residential) (SA-R) activities are those provided for the treatment of drug or alcohol use disorders in a residential setting to include screening, assessment, diagnosis, and treatment of substance use disorder.

Program Guidance:

Substance Abuse Services (residential) is permitted only when the client has received a written referral from the clinical provider as part of a substance use disorder treatment program funded under the HRSA Ryan White HIV/AIDS Program (RWHAP). Acupuncture therapy may be allowable cost under this service category only when it is included in a documented plan as part of a substance use disorder treatment program funded under the HRSA RWHAP.

Language assistance must be provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services.

Subrecipients must provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.

All AAs and subrecipients must establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.

Limitations:

HRSA RWHAP funds may not be used for inpatient detoxification in a hospital setting, unless the detoxification facility has a separate license.

Services:

Services include:

Pretreatment/recovery readiness programs
Healthy behavior promotion
Behavioral health counseling associated with substance use disorder
Medication assisted therapy
Neuro-psychiatric pharmaceuticals
Relapse prevention
Detoxification, if offered in a separate licensed residential setting (including a separately licensed detoxification facility with the walls of an inpatient medical or psychiatric hospital)

Services will be provided in accordance with the Texas Health and Safety Code, Title 6, Subtitle B, Chapter 464 and the Texas Administrative Code, Title 25, Part 1, Chapter 448 for Substance Abuse Standards of Care.

Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services. For the Ryan White Part B/SS funded providers and Administrative Agencies, telehealth and telemedicine services are to be provided in real-time via audio and video communication technology which can include videoconferencing software.

DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA). Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.

Service Standard and Measure

The following Standards and Measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard	Measure
Initial Screening: Each client will be screened for Substance Abuse Residential services based on best practice standards of care with use of the Texas Department of Insurance criteria per the Texas Administrative Code (TAC) standards for Substance Abuse Services. The screening process shall collect information necessary to determine the type of services that are required to meet the client’s needs. [1] To be eligible for admission to a treatment program, an individual must meet the DSM criteria for substance use or dependence (or substance withdrawal or intoxication in the case of a detoxification program). [1]	Percentage of client charts that will have documentation of completed screening as indicated.
Comprehensive Psychosocial Assessment: All clients referred to the program will receive a Comprehensive Psychosocial Assessment by a licensed substance use disorder counselor. Initial comprehensive psychosocial assessment protocols shall provide for screening individuals to determine level of need and appropriate development of treatment plan. A comprehensive assessment will be signed and placed within the client record within three (3) individual service days of admission: Presenting problems resulting in need; Alcohol and other substance use; Psychiatric and chemical dependency treatment; Medical history and current health status, to include an assessment of Tuberculosis (TB), HIV and other sexually transmitted infections (STI) risk behaviors as permitted by law; Relationships with family including domestic/intimate partner violence History of trauma/related events; Stigma; Housing stability, Expelled from home; Treatment adherence (e.g. HIV meds); Social and leisure activities; Education and vocational training; Employment history; Legal issues; Mental/emotional functioning; and Strengths/challenges. [1] The assessment shall result in a diagnosed substance use issue, as allowed by the license and scope of practice of the counselor. *Note: Clients are assessed for care coordination needs, and referrals are made to other case management programs as appropriate. If pressing needs emerge during the assessment requiring immediate attention that results in the assessment not being finalized by the third session, this must be documented in the client’s primary record. Specific assessment tools such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) may be used for substance use and sexual history, and the Mini Mental State Examination (MMSE) may be used for cognitive assessment. A copy of the assessment(s) will be offered/provided to the client. Residential clients must have a documented health assessment conducted by a licensed health professional within 96 hours of admission per the TAC Standards of Care.	Percentage of client charts that have documentation of initial comprehensive psychosocial assessments completed as indicated. Percentage of client charts with documented use of assessment tools as indicated for substance use and sexual history. Percentage of client charts with documented use of assessment tool as indicated for cognitive assessment. Percentage of client charts with documented evidence of a health assessment completed within 96 hours of admission.
Treatment Modalities: Providers should discuss treatment options with clients who use substances and should ask which treatment options they prefer. Providers should inquire about use of multiple substances and should consider the full spectrum of the client’s use of substances when discussing treatment options with the client. Providers must discuss alternative treatment modalities with the client that are focused on the substance(s) that the client is still using. Providers must rely on the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) for guidance on selecting the best treatment alternatives for specific clients. Medical treatment for substance use must adhere to current HIV Clinical Guidelines. Staff will document all treatment services (modalities) in the client primary record within 72 hours including the date, nature, and duration of the contact per TAC Standards. Signature and credentials of the counselor providing treatment must be documented. Clients accessing detox programs have evidence of a signed client consent for treatment.	Percentage of client charts with documentation of discussion of treatment modalities with the client. Percentage of client charts with documented treatment services within 72 hours, including date, nature, and duration with staff signature and credentials present in the client record. Percentage of client charts for clients accessing detox programs with evidence of client consent.
Treatment Plan: A treatment plan shall be completed and filed in the client record within five (5) individual service days of admission (per TAC Standards). The treatment plan shall be prepared and documented for each client. Treatment planning will be a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them. The treatment plan will include: Goals, objectives, and strategies; Identification of discharge criteria and include initial plans for discharge; Projected length of stay; Identify client’s primary counselor. The treatment plan will be signed and dated by the substance use counselor rendering service. In accordance with TAC on Substance Use, the treatment plan shall be evaluated on a regular basis and revised as needed to reflect the ongoing reassessment of the client’s issues, needs, and response to treatment. At a minimum, the treatment plans will be reassessed/reviewed midway through the projected duration of treatment and no less frequently than monthly in residential programs according to TAC standards.	Percentage of client charts with documentation of treatment plans completed within five individual service days of admission. Percentage of client charts with documented evidence of updated treatment plans, at a minimum, midway through the projected duration of the treatment or at least monthly for residential programs.
Progress Notes: Services will be provided according to the individual's treatment plan and documented in the client's record. Progress notes are completed for every professional counseling session and should include: Client name Session date Clinical observations Focus of session Interventions Assessment Duration of session Newly identified issues/goals Client’s responses to interventions and referrals HIV medication adherence Substance use treatment adherence Counselor authentication, in accordance with current TAC standards Detox program progress notes: Progress notes are completed for all clients accessing detox programs that include: Vitals assessed Medications provided to client during detox program Medical evaluation(s) Discussion regarding transition plan after detox program completed	Percentage of client charts with documented progress notes for each counseling session as indicated. Percentage of client charts with evidence of progress notes documented as indicated for clients who are accessing detox programs.
Referrals: Agency will make appropriate referrals when necessary. For clients accessing detox programs, evidence of referrals to outpatient and/or residential substance use programs for continuity.	Percentage of client charts, as applicable, with documented referrals made based on need demonstrated in the assessment and progress notes.
Discharge Planning: Discharge planning will be done with each client through treatment. The discharge plan shall address continuity of services to the client per TAC standards. Discharge planning shall be completed before the client’s scheduled discharge. A written discharge plan shall be developed to address ongoing client needs, including: Individual goals or activities to sustain recovery; Referrals after completing substance use treatment to case manager and/or primary care provider, as appropriate; and Recovery maintenance services, if applicable. Discharge plans will be dated and signed by the counselor and the client per TAC standards. In all cases, providers/case managers shall ensure that, to the greatest extent possible, clients who leave care are linked with appropriate services to meet their needs.	Percentage of client charts with documentation, as applicable, of discharge planning with the client prior to discharge from the residential program.
Discharge Summary: A discharge summary will be completed for each client within 30 days of discharge per TAC standards. The discharge summary will be signed by the counselor and will include: Dates of admission and discharge; Needs and issues identified at the time of admission, during treatment, and at discharge; Services provided; Assessment of the client’s progress towards goals; Reason for discharge; and Referrals and recommendations, including arrangements for recovery maintenance. The facility, per TAC requirements, will contact each client no sooner than 60 days and no later than 90 days after discharge from the residential program and document the client’s current status or reason the contact was unsuccessful.	Percentage of client charts with documentation of discharge summary completed within 30 days of discharge. Percentage of clients with documented evidence of attempts to contact client no later than 90 days after discharge with client’s current status or reason the contact was unsuccessful.

Standard

Measure

Initial Screening: Each client will be screened for Substance Abuse Residential services based on best practice standards of care with use of the Texas Department of Insurance criteria per the Texas Administrative Code (TAC) standards for Substance Abuse Services. The screening process shall collect information necessary to determine the type of services that are required to meet the client’s needs. [1]

To be eligible for admission to a treatment program, an individual must meet the DSM criteria for substance use or dependence (or substance withdrawal or intoxication in the case of a detoxification program). [1]

Percentage of client charts that will have documentation of completed screening as indicated.

Comprehensive Psychosocial Assessment: All clients referred to the program will receive a Comprehensive Psychosocial Assessment by a licensed substance use disorder counselor. Initial comprehensive psychosocial assessment protocols shall provide for screening individuals to determine level of need and appropriate development of treatment plan.

A comprehensive assessment will be signed and placed within the client record within three (3) individual service days of admission:

Presenting problems resulting in need;
Alcohol and other substance use;
Psychiatric and chemical dependency treatment;
Medical history and current health status, to include an assessment of Tuberculosis (TB), HIV and other sexually transmitted infections (STI) risk behaviors as permitted by law;
Relationships with family including domestic/intimate partner violence
History of trauma/related events;
Stigma;
Housing stability, Expelled from home; Treatment adherence (e.g. HIV meds);
Social and leisure activities;
Education and vocational training;
Employment history;
Legal issues;
Mental/emotional functioning; and
Strengths/challenges. [1]

The assessment shall result in a diagnosed substance use issue, as allowed by the license and scope of practice of the counselor.

*Note: Clients are assessed for care coordination needs, and referrals are made to other case management programs as appropriate. If pressing needs emerge during the assessment requiring immediate attention that results in the assessment not being finalized by the third session, this must be documented in the client’s primary record.

Specific assessment tools such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) may be used for substance use and sexual history, and the Mini Mental State Examination (MMSE) may be used for cognitive assessment.

A copy of the assessment(s) will be offered/provided to the client.

Residential clients must have a documented health assessment conducted by a licensed health professional within 96 hours of admission per the TAC Standards of Care.

Percentage of client charts that have documentation of initial comprehensive psychosocial assessments completed as indicated.

Percentage of client charts with documented use of assessment tools as indicated for substance use and sexual history.

Percentage of client charts with documented use of assessment tool as indicated for cognitive assessment.

Percentage of client charts with documented evidence of a health assessment completed within 96 hours of admission.

Treatment Modalities: Providers should discuss treatment options with clients who use substances and should ask which treatment options they prefer.

Providers should inquire about use of multiple substances and should consider the full spectrum of the client’s use of substances when discussing treatment options with the client.

Providers must discuss alternative treatment modalities with the client that are focused on the substance(s) that the client is still using.

Providers must rely on the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) for guidance on selecting the best treatment alternatives for specific clients.

Medical treatment for substance use must adhere to current HIV Clinical Guidelines.

Staff will document all treatment services (modalities) in the client primary record within 72 hours including the date, nature, and duration of the contact per TAC Standards. Signature and credentials of the counselor providing treatment must be documented.

Clients accessing detox programs have evidence of a signed client consent for treatment.

Percentage of client charts with documentation of discussion of treatment modalities with the client.

Percentage of client charts with documented treatment services within 72 hours, including date, nature, and duration with staff signature and credentials present in the client record.

Percentage of client charts for clients accessing detox programs with evidence of client consent.

Treatment Plan: A treatment plan shall be completed and filed in the client record within five (5) individual service days of admission (per TAC Standards). The treatment plan shall be prepared and documented for each client. Treatment planning will be a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them.

The treatment plan will include:

Goals, objectives, and strategies;
Identification of discharge criteria and include initial plans for discharge;
Projected length of stay;
Identify client’s primary counselor.

The treatment plan will be signed and dated by the substance use counselor rendering service.

In accordance with TAC on Substance Use, the treatment plan shall be evaluated on a regular basis and revised as needed to reflect the ongoing reassessment of the client’s issues, needs, and response to treatment. At a minimum, the treatment plans will be reassessed/reviewed midway through the projected duration of treatment and no less frequently than monthly in residential programs according to TAC standards.

Percentage of client charts with documentation of treatment plans completed within five individual service days of admission.

Percentage of client charts with documented evidence of updated treatment plans, at a minimum, midway through the projected duration of the treatment or at least monthly for residential programs.

Progress Notes: Services will be provided according to the individual's treatment plan and documented in the client's record. Progress notes are completed for every professional counseling session and should include:

Client name
Session date
Clinical observations
Focus of session
Interventions
Assessment
Duration of session
Newly identified issues/goals
Client’s responses to interventions and referrals
HIV medication adherence
Substance use treatment adherence
Counselor authentication, in accordance with current TAC standards

Detox program progress notes: Progress notes are completed for all clients accessing detox programs that include:

Vitals assessed
Medications provided to client during detox program
Medical evaluation(s)
Discussion regarding transition plan after detox program completed

Percentage of client charts with documented progress notes for each counseling session as indicated.

Percentage of client charts with evidence of progress notes documented as indicated for clients who are accessing detox programs.

Referrals: Agency will make appropriate referrals when necessary. For clients accessing detox programs, evidence of referrals to outpatient and/or residential substance use programs for continuity.

Percentage of client charts, as applicable, with documented referrals made based on need demonstrated in the assessment and progress notes.

Discharge Planning: Discharge planning will be done with each client through treatment. The discharge plan shall address continuity of services to the client per TAC standards. Discharge planning shall be completed before the client’s scheduled discharge.

A written discharge plan shall be developed to address ongoing client needs, including:

Individual goals or activities to sustain recovery;
Referrals after completing substance use treatment to case manager and/or primary care provider, as appropriate; and
Recovery maintenance services, if applicable.

Discharge plans will be dated and signed by the counselor and the client per TAC standards.

In all cases, providers/case managers shall ensure that, to the greatest extent possible, clients who leave care are linked with appropriate services to meet their needs.

Percentage of client charts with documentation, as applicable, of discharge planning with the client prior to discharge from the residential program.

Discharge Summary: A discharge summary will be completed for each client within 30 days of discharge per TAC standards. The discharge summary will be signed by the counselor and will include:

Dates of admission and discharge;
Needs and issues identified at the time of admission, during treatment, and at discharge;
Services provided;
Assessment of the client’s progress towards goals;
Reason for discharge; and
Referrals and recommendations, including arrangements for recovery maintenance.

The facility, per TAC requirements, will contact each client no sooner than 60 days and no later than 90 days after discharge from the residential program and document the client’s current status or reason the contact was unsuccessful.

Percentage of client charts with documentation of discharge summary completed within 30 days of discharge.

Percentage of clients with documented evidence of attempts to contact client no later than 90 days after discharge with client’s current status or reason the contact was unsuccessful.

Note:

[1] Texas Administrative Code, Title 25, Part 1, Chapter 448