Substance Abuse Services (Residential)

Initial Screening: Each client must be screened for SA-R services based using the Texas Department of Insurance criteria per the TAC standards for substance abuse services. The screening process should collect all information necessary to determine the type of services required to meet the client’s needs.

To be eligible for admission to a treatment program, an individual must meet the current Diagnostic and Statistical Manual (DSM) criteria for substance use or dependence (or substance withdrawal or intoxication in the case of a detoxification program).

1. Percentage of client charts with documentation of a completed initial screening.

Comprehensive Psychosocial Assessment: All clients must receive a comprehensive psychosocial assessment conducted by a licensed substance use disorder counselor. The comprehensive assessment should be completed and signed within 3 days of admission, and a copy of the completed assessment should be offered and provided to the client. If emergent needs prevent the assessment from being completed within 3 days, this must be documented in the client’s record.

The comprehensive assessment should include:

• Presenting problem(s)
• Alcohol and other substance use
• Previous psychiatric and chemical dependency treatment
• Medical history, including current HIV treatment and level of adherence
• Relationships with family, including domestic/intimate partner violence
• History of trauma
• Housing status
• Social and leisure activities
• Education and vocational training
• Employment history
• Legal issues
• Cognitive status
• Strengths and challenges

During the initial assessment, clients should be assessed for care coordination needs and referrals should be made to case management or other support programs as appropriate.

A valid and reliable assessment tool such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and Addiction Severity Index (ASI) should be used to evaluate substance use. The Mini Mental State Examination (MMSE) or other validated tool may be used for cognitive assessment. 

Residential clients must have a health assessment conducted by a licensed health professional within 96 hours of admission per 25 TAC Section 488.803.

2. Percentage of clients with an initial comprehensive psychosocial assessment completed within 3 days of admission.
    
3. Percentage of clients evaluated using a valid and reliable assessment tool for substance use.
    
4. Percentage of clients evaluated using a valid and reliable assessment tool for cognitive assessment.
    
5. Percentage of clients with a health assessment completed within 96 hours of admission.

Treatment Plan: A treatment plan should be completed and filed in the client record within 5 days of admission. Treatment planning should be a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them. Providers should discuss all available treatment options with the client and incorporate the client’s wishes regarding the treatment course and modality.

The treatment plan should include:

• Goals and objectives of treatment
• Treatment modalities and interventions to achieve treatment goals
• Discharge criteria and initial plans for discharge
• Projected length of stay
• Client’s primary counselor
• Signature and date of the counselor developing the treatment plan

The treatment plan should 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, treatment plans must be reviewed and updated midway through the projected duration of treatment and no less frequently than monthly.

6. Percentage of clients with treatment plans completed within 5 days of admission.
    
7. Percentage of clients with treatment plans updated midway through the projected duration of the treatment at a minimum, and no less frequently than monthly.

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

• Client name
• Session date
• Clinical observations
• Focus of the session
• Interventions
• Assessment
• Duration of session
• Newly identified issues/goals
• Client’s responses to interventions and referrals
• HIV medication adherence
• Substance use treatment adherence
• Signature of the counselor conducting the session

For detox program clients, notes should include:

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

8. Percentage of clients with progress notes for each counseling session.
    
9. Percentage of clients accessing detox programs with progress notes.

Referrals: Agencies must make appropriate referrals for clients with medical or support needs. For clients accessing detox programs, referrals should be made to outpatient and/or residential substance use programs for continuity of care.

10. Percentage of clients with referrals based on need demonstrated in the assessment and progress notes, as applicable.

Discharge Planning: Discharge planning should be conducted collaboratively with all clients and completed before the client’s scheduled discharge. A written discharge plan must be developed to address ongoing client needs and continuity of services, and should include:

• Individual goals or activities to sustain recovery
• Referrals to case management and/or primary care providers, as appropriate
• Outpatient substance abuse services and other recovery maintenance services, as applicable
• Date and signatures of the counselor and client

11. Percentage of clients with a completed discharge plan prior to discharge from the residential program.

Discharge Summary: A discharge summary must be completed for each client within 30 days of discharge and should 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 toward goals
• Reason for discharge
• Referrals and recommendations, including arrangements for recovery maintenance
• Signature of the counselor 

The facility must 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 the reason contact was unsuccessful.

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of case closure or graduation, unless the case is being closed due to a deceased client.

12. Percentage of clients with a discharge summary completed within 30 days of discharge.
     
13. Percentage of clients with documentation of attempts to contact the client 60-90 days after discharge with the client’s current status or the reason contact was unsuccessful.