Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This rule sets forth requirements for
operation of a sobering center.
(1) Definitions. Unless the context clearly
requires otherwise, the following terms as used in this rule shall mean-
(A) Sobering center, short-term care facility
designed to allow an individual who is intoxicated and nonviolent to safely
recover from the immediately debilitating effects of alcohol and drugs.
Sobering centers typically operate twenty-four (24) hours per day, seven (7)
days per week and provide supervised care for individuals experiencing acute
intoxication for up to twenty-three (23) consecutive hours; and
(B) Acute intoxication, a transient condition
that follows the ingestion or consumption of alcohol or a psychoactive
substance and results in disturbances in the level of consciousness, cognition,
perception, judgment, affect or behavior, or other psychophysiological
functions and responses.
(2) Program Description. Sobering centers are
operated by a Certified Community Behavioral Health Organization (CCBHO).
(A) Services shall be designed to serve as a
community-based alternative to emergency department services, unnecessary
hospitalization, and/or jail confinement, offering short-term stabilization for
individuals experiencing acute intoxication.
(3) Certification. At a minimum, the
organization shall comply with
9 CSR
10-7.130 Procedures to Obtain Certification, to apply
for certification/deemed status as a sobering center by the
department.
(4) Program
Requirements. Sobering centers shall provide prompt assessment, stabilization
(with or without medication), and determination of appropriate monitoring
needed for the individual to return to a state of clinical sobriety.
(A) Services shall be designed to address
acute intoxication with the goal of symptom reduction as evidenced by-
1. Eating, drinking, and/or swallowing
without difficulty;
2. Walking
without ataxia or unsteady gait;
3.
Baseline mental status representing unimpaired cognition; and
4. Cognitive status supporting reasonable
decisions.
(B) Referrals
to community resources and/or treatment and recovery services shall be made, as
appropriate.
(5) Target
Population. The target population includes individuals age eighteen (18) years
and older who are experiencing acute intoxication and have a high or imminent
risk of law enforcement contact and/or emergency department
intervention.
(6) Physical
Environment and Safety. All sobering centers shall be in compliance with
9 CSR
10-7.120 Physical Environment and Safety, and
applicable state and local building codes, fire codes, and ordinances to ensure
the health, safety, and security of all individuals.
(A) The physical environment shall-
1. Promote a sense of safety and calm for
individuals and staff;
2. Have
adequate space to ensure the comfort of individuals served;
3. Have adequate space to ensure privacy and
confidentiality for individuals served;
4. Have furnishing and fixtures that are
constructed of durable materials not capable of breakage into pieces that could
be used as a weapon, ligature risk, or for self-harm; and
5. Have interior finishes, lighting, and
furnishings that suggest a non-institutional setting that conforms to
applicable fire and safety codes.
(7) Care Criteria. Each sobering center shall
implement written screening and intake criteria for individuals who present for
services.
(A) All individuals who present for
services from a referral source shall be screened as specified in subsection
(7)(C) of this rule, including those who are referred/transported by law
enforcement.
1. Hours of operation shall be
clearly communicated to law enforcement and other referral
sources.
(B) If in-person
screening results in an individual not being offered services, documentation of
the rationale for the denial of services and facilitated referral of the
individual to other appropriate services must be maintained.
(C) Service criteria shall include, but is
not limited to-
1. Presence of acute
intoxication; and
2. Presence of
high or imminent risk of law enforcement contact and/or emergency department
intervention.
(D) Medical
clearance is not required prior to provision of services; however, each
individual served must be able to ambulate with minimal assistance, including
the use of assistive devices required for existing medical conditions.
1. Individuals referred from a hospital must
meet medical stability eligibility criteria.
2. If a physical health issue requiring
medical care occurs that cannot be addressed while an individual is receiving
services in the sobering center, the treating center shall arrange for the
individual to be appropriately transported to a medical facility to address the
physical health issue.
(E) As appropriate, medications (including
medication-assisted treatment for a substance use disorder) shall be prescribed
while coordinating ongoing services with the individual.
(8) Staff Qualifications. The sobering center
shall be adequately staffed to meet the needs of individuals served to ensure
their safety and the safety of staff.
(A) Each
center shall have the staffing capacity to monitor vital signs with established
written protocols to transfer an individual to a medical facility, if
needed.
(B) The center shall be
staffed by a multidisciplinary team that is able to respond to the needs of
individuals experiencing acute intoxication. Staff shall include, but is not
limited to-
1. Medical director, a licensed
physician. The medical director for the sobering center can be the same
individual who serves as the medical director for the Certified Community
Behavioral Health Organization (CCBHO).
A.
Direct services shall be provided by a licensed physician (includes
psychiatrist), resident physician (includes psychiatrist), physician assistant,
assistant physician, licensed psychiatric mental health nurse practitioner
(PMHNP), and/or advanced practice registered nurse (APRN) who is in a written
collaborative practice arrangement with a physician and with experience
treating the target population. Services may be provided via
telemedicine;
2.
Qualified practitioner(s) to treat opioid use disorders with narcotic
medications approved by the Food and Drug Administration (methadone must be
provided by a certified opioid treatment program);
3. Clinical program director, a qualified
mental health professional (QMHP) to oversee program operations and clinical
practice, with experience treating the target population;
4. Nurse, paramedic, or emergency medical
technician (EMT); and
5. Certified
peer specialist(s).
(9) Staff Coverage. Staff coverage shall
ensure the continuous supervision and safety of individuals served. Staff
coverage shall be determined by the sobering center.
(A) At a minimum, coverage shall include-
1. Two (2) behavioral health staff who are
on-site during receiving hours;
2.
One (1) QMHP who is available during receiving hours (may be via
telemedicine);
3. One (1) nurse,
paramedic, or EMT who is available during receiving hours (may be via
telemedicine); and
4. A physician
or resident physician (including psychiatrist), assistant physician, physician
assistant, PMHNP, and/or APRN, who is available during receiving hours and must
immediately respond to calls from staff, delay not to exceed one (1)
hour.
(B) Qualified staff
must be available to administer, screen, inventory, and store prescribed
medications within their scope of duties, practice, and/or training.
(C) Qualified staff, within their scope of
duties, practice, and/or training, shall be available to conduct an initial
health assessment and utilize evidence-based tools to determine the
individual's medical stability, intoxication, substance use, and/ or level of
withdrawal/impairment.
(10) Policies and Procedures. The sobering
center shall maintain and implement written policies and procedures including
but not limited to-
(A) Intake screening,
service, and clinical assessment protocols;
(B) Community outreach and education
strategies for acute intoxication stabilization services including access to
and location of service site(s), hours, and days of operation for each site
through written material and other means of communication, and how these
components will be accomplished on an ongoing basis;
(C) Withdrawal management (detoxification)
services as defined in
9 CSR
30-3.120. If the sobering center does not provide this
service, facilitated referrals to a local hospital or another qualified service
provider shall be made for withdrawal management or other medical services, if
determined necessary during an individual's evaluation process;
(D) Safety and emergency protocols as
specified in 9 CSR 10-7.120 Physical
Environment and Safety, as well as specific protocols for the population
served;
(E) Prescription medication
protocols, including storage of medications in accordance with
9 CSR
10-7.070;
(F) Screening for and accessing services for
emergency medical conditions, including transport by first responders/
emergency medical service;
(G)
Monitoring the physical and psychological well-being of individuals including
but not limited to respiratory and circulatory status, skin integrity, vital
signs, and any special requirements specified in the organization's policies
and procedures associated with evaluations;
(H) Linking individuals to housing services
upon discharge, as needed;
(I)
Linking individuals to transportation services upon discharge, as
needed;
(J) Linking individuals to
social services or community resources, as needed;
(K) Assessment and referral process for
individuals with a suspected substance use disorder and/or mental health
disorder;
(L) Care coordination and
continuity of care for individuals served including but not limited to referral
process, follow-up, and transfer of records within five (5) days, as
applicable;
(M) Infection
prevention and control; and
(N)
Exclusion criteria and protocol when the sobering center is not able to provide
services to an individual.
(11) Referral Sources. At a minimum, the
following are required referral sources for consideration for admission:
(A) Law enforcement;
(B) Emergency medical services;
(C) Other first responders;
(D) Engaging Patients in Care Coordination
(EPICC) Coaches;
(E)
Community-based organizations participating in department supported outreach
services;
(F) Local hospitals,
primary care clinics, urgent care clinics, and Federally Qualified Health
Centers (FQHC);
(G) Community
Behavioral Health Liaisons; and
(H)
Mobile Crisis Response.
(12) Community Partnerships. At a minimum,
sobering centers shall have a referral relationship, collaborative agreement,
and/or memorandum of understanding (MOU) with the following community
providers/agencies:
(A) Qualified providers of
withdrawal management services;
(B)
Housing supports;
(C) Local
hospitals, primary care clinics, and FQHCs;
(D) Local Continuum(s) of Care; and
(E) Recovery support and recovery housing
providers.
(13)
Coordination and Continuity of Care. Service coordination and continuity of
care efforts shall include, but are not limited to:
(A) Identifying and linking individuals with
available community resources necessary to ensure transition to routine
care;
(B) Referring individuals to
behavioral health services, if they are not already receiving those
services;
(C) Connecting and/or
referring individuals to appropriate local resources including emergency room
enhancement (ERE) staff, community behavioral health liaisons (CBHL), and/ or
certified peer specialists who shall conduct and document timely follow-up to
determine the individual's current status and need for additional assistance or
services;
(D) Contacting and
coordinating care with current service providers when feasible and in
accordance with state and federal confidentiality regulations;
(E) Connecting individuals to housing, food,
or other resources;
(F) Connecting
individuals with recovery support and/or recovery housing providers;
(G) Connecting individuals with
community-based behavioral health providers in other geographic regions;
and
(H) Incorporating intensive
support beds into a partner program (within the organization or with another
local agency), if available, for individuals who need additional support beyond
that of the sobering center.
(14) Documentation Requirements. Based on the
individual's ability to cooperate and communicate with staff due to their
presenting condition, the following intake documentation shall be obtained:
(A) Presenting problem and referral source,
if applicable;
(B) Rationale for
denial of services and referral of the individual to other appropriate
services, if necessary;
(C)
Personal and identifying information;
(D) Status as a current or former member of
the U.S. Armed Forces;
(E) Current
mental health and substance use symptoms;
(F) Current medications and any medications
administered;
(G) Screening for
suicide risk and completion of a comprehensive, standardized suicide risk
assessment and planning, when clinically indicated;
(H) Screening for risk of violence and
completion of a comprehensive, standardized violence risk assessment and
planning, when clinically indicated;
(I) Current concerns for personal safety;
and
(J) Discharge information
including services provided, care coordination efforts, follow-up, and
referrals.
(15) Measuring
Program Effectiveness. Sobering centers shall collect, enter, and submit data
utilizing all reporting tools as directed by the department.
(16) Staff Training and Education. Staff
shall comply with the training requirements specified in
9 CSR
10-7.110 Personnel, subsection (2)(F). All staff of
the sobering center shall complete minimum training requirements as follows:
(A) Screening, assessment, and planning for
risk of suicide;
(B) Screening,
assessment, and planning for risk of violence;
(C) Evidence-based and best practice
interventions to prevent and address disruptive behaviors and behavioral
crises;
(D) Basic First
Aid;
(E) Cardiopulmonary
Resuscitation (CPR);
(F)
Administration of naloxone; and
(G)
Trauma-informed care.
