Eligibility: A clinical provider must place a written referral for SA-R as part of a substance use disorder treatment program funded under the RWHAP.

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 written referral from a clinical provider for residential substance use disorder treatment or detoxification. (Pilot Measure 2025-2026)

Comprehensive Assessment: A Licensed Chemical Dependency Counselor (LCDC) or other qualified professional must complete a comprehensive psychosocial assessment for all clients. Professional staff must complete the comprehensive assessment within 96 hours of admission and offer to provide the client with a copy of the completed assessment. If emergent needs prevent the completion of the assessment within 96 hours, staff must document this in the client’s record. 

The assessment must include 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 

During the initial assessment, providers should assess clients for care coordination needs and make referrals to case management or other support programs as appropriate.

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 also use other industry-recognized assessment tools if approved by the provider agency.

A licensed health professional must conduct a health assessment for all residential clients within 96 hours of admission per 26 Texas Administrative Code § 564.803.

2. Percentage of clients with an initial comprehensive assessment completed within 96 hours of admission.
    
3. Percentage of clients with a health assessment completed within 96 hours of admission.

Treatment Plan: Staff must complete a treatment plan and file it in the client record within five days of admission. Treatment planning is 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 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. For clients accessing detox programs, staff should make referrals to outpatient or residential substance use programs for continuity of care.

Staff must evaluate the treatment plan regularly and revise it as needed to reflect the ongoing reassessment of the client’s concerns, needs, and response to treatment. At a minimum, agencies must review and update treatment plans midway through the projected duration of treatment and no less frequently than monthly.

4. Percentage of clients with treatment plans completed within five days of admission.
    
5. 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: 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 concerns or 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:

• Client name
• Evaluation date
• Vitals assessed
• Medications provided to the client during a detox program
• Medical evaluation(s)
• Discussion regarding the transition plan after the completion of the detox program

6. Percentage of clients in counseling programs with progress notes for each counseling session.
    
7. Percentage of clients accessing detox programs with progress notes.

Discharge Planning: Providers must conduct discharge planning collaboratively with clients and complete planning before the client’s scheduled discharge. A written discharge plan must address ongoing client needs and continuity of services and must include:

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

Providers and case managers should ensure that they link clients who leave care with appropriate services to meet their needs to the greatest extent possible. When a client voluntarily leaves services before completing discharge planning, staff should document the circumstances of discharge in the discharge summary.

8. Percentage of clients with a completed discharge plan before discharge from the residential program.

Discharge Summary: Staff must complete a discharge summary for each client within 30 days of discharge and must include:

• Dates of admission and discharge
• Needs and concerns 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.

9. Percentage of clients with a discharge summary completed within 30 days of discharge.
    
10. 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.