• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (512) 533-3000

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Substance Abuse Services (Residential)

Standards of Care

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HRSA Definition:

Substance Abuse Services (Residential) is the provision of services for the treatment of drug or alcohol use disorders in a residential setting to include screening, assessment, diagnosis, and treatment of substance use disorder.

 

Limitations:

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
  • Harm reduction
  • 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)

 

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 RWHAP. Acupuncture therapy may be allowable funded 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 RWHAP.

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. 

 

Service Standard and Performance Measure

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

Standards
Standard Performance 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 abuse 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 drug 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 vocation training;
  • Employment history;
  • Legal issues;
  • Mental/emotional functioning; and
  • Strengths and weaknesses. [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 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 substance using clients 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 drug use when discussing treatment options with the client.

Providers must discuss alternative treatment modalities with the client that are targeted toward 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 that have 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 Abuse, the treatment plan shall be evaluated on a regular basis and revised as needed to reflect the ongoing reassessment of the client’s problems, 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 that have documentation of treatment plans completed within 5 individual service days of admission.

Percentage of client charts have 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 who are accessing detox programs that have evidence of progress notes documented as indicated.

Referrals: Agency will make appropriate referrals out 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 discharge for the residential program.

Discharge Summary: A discharge summary will be completed for each client within 3 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 problems 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.

 

References

Department of State Health Services Substance Abuse Treatment Facilities

Department of State Health Services HIV Workplace Guidelines

HRSA/HAB Division of Metropolitan HIV/AIDS Programs Program Monitoring Standards – Part A April 2013. p. 17-18

HRSA/HAB Division of State HIV/AIDS Programs National Monitoring Standards – Program Part B April, 2013. p. 17-18

New York HIV Clinical Guidelines for Substance Use Treatment Modalities

Texas Administrative Code, Title 22, Part 30, Chapter 681 - Texas Board of Examiners of Professional Counselors

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

Texas Health and Safety Code, Title 6. Food, Drugs, Alcohol, and Hazardous Substances, Subtitle B. Alcohol and Substance Abuse Programs, Chapter 464

Texas Administrative Code, Title 25. Part 1, Chapter 448 Standards of Care, Subchapter H Screening and Assessment

 

Note:

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


Last updated January 23, 2018